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Background Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra. Objective To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction. Design, setting, and participants Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study. Surgical procedure The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula. Measurements Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure. Results and limitations We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5–8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5–26 ml/min). The median follow-up was 25 mo (IQR 10–30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique. Conclusions In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra. Patient summary Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.

The inspection of the urethra in patients with documented or suspected urethral stricture should be carried out with small caliber ureteroscope of 6/7.5Ch. Different from flexible cystoscope (16Ch) or resectoscope (26Ch), small caliber ureteroscope allows a comprehensive evaluation of the stricture, including its length and the status of the mucosa in its proximity, without injuring or overstretching the urethra. With a small caliber ureteroscope it is also possible to cross the stricture, allowing the evaluation of the proximal urethra, the external urethral sphincter, and the bladder. A 6/7.5Ch ureteroscope also allows estimation of the real caliber of the stricture, providing a useful landmark for further treatment decisions.

Objective: To define the role of tadalafil in improving outcomes of redo urethroplasty for pelvic fracture urethral injury (PFUI). PFUI is common in developing countries, invariably as a result of road traffic trauma. Repair is complex, and redo cases are even more challenging. Material and methods: This was a longitudinal prospective nonrandomized study between 2017 and 2019. Men undergoing redo-urethroplasty were nonrandomized into two groups. Group 1 received tadalafil 5 mg the next day after surgery and continued for 3 months, and group 2 did not receive tadalafil. Inclusion criteria were patients undergoing redo-urethroplasty willing to trial low-dose tadalafil post-operatively. Exclusion criteria were 1 endoscopic intervention. Primary success was 83.3%. Success with tadalafil was 96.6%, compared to 71.0% in the non-Tadalafil group (P = .0008). Only one patient on tadalafil failed, compared with nine in the non-tadalafil group. Secondary success rate was defined as the need for a single subsequent endoscopic intervention and was 93.3%. Conclusion: In our series, there was improved outcome with using tadalafil in patients having redo urethroplasty for PFUI. Further trials should be done to evaluate the use in all PFUI cases.

Objective The urethral gap in pelvic fracture urethral injury (PFUI) is traditionally assessed using voiding cystourethrogram (VCUG) and retrograde urethrogram (RGU). Magnetic resonance imaging (MRI) is performed in complex cases. We assessed the refined "Joshi" MRI protocol to evaluate complex urethral defects after PFUI. Material and methods A prospective study was conducted at our center from January 2018 to January 2020, involving patients aged >18 years with PFUI, suitable for MRI, and those who gave consent to perform standard RGU, VCUG, and MRI using standard and "Joshi" protocol. Forty men were included in the study. Distance between urethral/prostatic stumps was measured. Image quality was scored by four radiologists and four urologists. The surgical approach and type of PFUI repair were noted. We also established the need for inferior pubectomy by assessing the position of the posterior urethra (membranous) in relation to a horizontal line drawn from the lower edge of the pubic bone anteriorly to the rectum posteriorly in a sagittal image. Results The mean age was 30 years (SD, 5.25; range, 21-43), and the time from injury to imaging was 4 months (3-10 months); 40% of the men underwent crural separation, 57.5%, inferior pubectomy, and 2.5%, crural rerouting. There was a difference of 0.3 to 1.1 cm in the urethral gap measurements between MR images using the standard versus "Joshi" technique. MRI identified complex injuries such as rectourethral fistula, the need for inferior pubectomy, and the orientation of the posterior urethra. Urologists' and radiologists' satisfaction scores for the MR images were satisfactory to excellent. If the posterior urethra was over the defined mark, there was a 100% likelihood of inferior pubectomy (23/40 patients). Conclusion MR image acquisition using the "Joshi" protocol provided high-quality anatomical information in PFUI cases to assist with surgical planning.

Objective Urethral strictures in women are rare compared with those in men. Three defined approaches for their treatment have been mentioned in the available literature: dorsal onlay, ventral onlay, and ventral inlay. Here we describe double-face buccal graft urethroplasty, a new technique for treating obliterative urethral strictures in women. Material and methods A 37-year-old woman presented with a catheter-induced stricture, multiple dilatations for which had failed. Micturating urethrogram revealed near-obliterative mid and distal strictures. An inlay incision was made in the posterior wall and then the anterior wall. A buccal graft was inserted as a double-face dorsal and ventral inlay in the urethra. Results The patient had normal unobstructed voiding during a follow-up of 6 months. Conclusion Double-face buccal graft urethroplasty is safe, feasible, and easy to perform and a good option for women with near-obliterative urethral strictures. To our knowledge, this is the first ever reported case of double-face urethroplasty in a woman.

Object Incidence of Post TURP strictures is between 2.2% and 9.8%. Stricture commonly occurs within the first 6 months. Our objective is to assess the outcomes of patients with obliterative strictures post-TURP (transurethral resection of prostate)that underwent a double-face urethroplasty. Methods This is a single-center prospective study of 17 patients with obliterative proximal bulbar stricture post-TURP who underwent double-face graft urethroplasty by two surgeons between Jan 2014 and Jan 2020. We defined post-TURP obliterative strictures as those patients who presented with complete or almost complete obstruction of the urethral lumen and who have had a history of acute urine retention. We have excluded patients with bladder neck contracture. Primary outcome was treatment success, defined as the no need for further treatments. Secondary outcome was post-urethroplasty continent rate. Results Seventeen patients were included in the study with median age of 66 years (interquartile range 40–77 years); median time of follow-up was 24 months (interquartile range 12–84 months); median stricture length was 4 cm (interquartile range 2–6 cm). Of the 17 patients, 15 were successful (88.2%). All patients were continent after urethroplasty. Conclusion With mid-term follow-up, treatment of obliterative proximal bulbar strictures with double-face buccal mucosa graft is a safe and effective procedure. Obliterative proximal bulbar strictures merit double face urethroplasty with high-rate success and functional outcomes.

INTRODUCTION AND OBJECTIVE:Voiding cystourethrogram (VCUG) plus retrograde urethrogram (RGU) is the standard of care after PFUDD. However, the relation between the urethral defect and the pubic bon...

INTRODUCTION AND OBJECTIVE:Pelvic fracture urethral injury (PFUI) is common in developing countries, invariably as a result of road traffic trauma. Repair is complex and redo cases are even more ch...

We quantify surgical success rate in the management of pelvic fracture urethral injury (PFUI) with repeat urethroplasty in the setting of two or more failed prior urethroplasties. A retrospective analysis was completed of a single surgeon urethroplasty database from Jan 1, 2012 to June 31, 2018. Patients with a history of PFUI recurrent urethral stricture despite two or more failed prior urethroplasty procedures were included. We identified 87 patients that had two more more failed prior urethroplasties. These had 2 main categories. One requiring anastomotic urethroplasty and other requiring substitution urethroplasty. Total success rate was 74.75% for anastomotic group and 84.61% for substitution group with a median follow-up of 34 months (range 6–60). Overall success rate for re redo Urethroplasty was 82.70%. Bulbar urethral ischemic necrosis was identified in 14 of 64 patients (21.9%). In these cases urethral substitution measures were performed including 12 with preputial flap and tubularization, 1 sigmoid colon substitution, medial thigh flap. No significant difference was observed between the success or failure group with respect to age, BMI, stricture length, number of prior urethroplasty procedure or endoscopic procedures or comorbidities. Our findings demonstrate that high success rates can be achieved for repeat urethroplasty in recurrent PFUI urethral stricture after two or more failed prior urethroplasty procedures. Bulbar urethral ischemic necrosis is a common finding in this patient population. Patients should be managed at a tertiary high volume referral center.

Pelvic fracture causes urethral injury in about 10% of patients. The etiology of injury is different in developing and developed world. While high-velocity automobile accidents are common in developed countries, where patients are in the car and there is usually a side impact, in the developing world, significant number of injuries are caused by two-wheeler accidents, pedestrians, farming accidents, fall from height, fall from tractor, fall from tree, and other causes like earthquake. We share our experience which is the largest in the reported literature. In our tertiary referral center, we get referrals from all across the globe. Since 1995 till 2018 we have performed 1307 surgeries for Pelvic fracture urethral injury. Our referrals are for complex urethroplasty. Our data from 1995–2018 was analyzed. Data after June 2018 was not included so as to have a minimum follow up of 6 months. 1296 patients were males and 11 were females. In the group of 1296 males, mean age was 32.4 years (range 1–79 years). The minimum follow-up was 6 months, and the median follow-up was 56.7 months (range 6.2–233.7). The overall success rate was 88.79% for primary cases while re-do urethroplasty patients had a success rate of 83.70%. The majority of our patients (more than 61.40%) needed inferior pubectomy: Of the total 1307 cases of urethroplasty for pelvic fracture urethral injury data was available for 1042 patients. Data were available for 1042 patients. The data from 2012 onwards were prospectively analyzed while the previous data were retrospectively analyzed. PFUI are common in the developing world. They tend to be more complex and have longer gaps as compared to developed world. This could be related to the anthropometric differences between races as well as nature of injury. They are best managed with delayed transperineal repair with excellent outcomes. Ancillary maneuvers are more frequently required. Re-do urethroplasty can achieve good results.

Objectives To describe, step by step, a new one-stage dorsal skin flap urethroplasty for penile stricture repair. Materials and methods The surgery was accomplished through a midline incision on the ventral penile surface, the urethra was fully dissected from the corpora cavernosa and longitudinally opened along its dorsal surface. A penile skin island, based on the dartos fascia flap, was dissected and moved over the corpora cavernosa, and the urethra was moved and sutured over the penile skin flap. Results Out of the 12 cases, 10 were classified successful and there were two failures. The operating time was 60 min. There was no postoperative fistula or urethral diverticulum. Conclusion Our modified Orandi's technique was easy and feasible, and avoided fistula and diverticulum formation after repair.

Pelvic fracture associated urethral injury (PFUI) is a sequel of blunt pelvic trauma. The published rate of urethral injury varies from 5-25% in different series. Management includes options from primary realignment to delayed anastomotic urethroplasty. Anastomotic urethroplasty include an elaborated progressive perineal approach and combined transpubic approach. Though the treatment and approach is well accepted across the globe, controversies do exist. Through this section we would debate the literature regarding some controversial issues in management of PFUI. The aim of this article was to evaluate and elucidate upon the controversies that surround the PFUI repair in this era.The following controversial and pertinent issues with respect to the repair of such injuries were reviewed: Primary realignment versus delayed repair of PFUI, Necessity of inferior pubectomy, Predictability of inferior wedge pubectomy, Spatulation of distal bulbar and proximal urethral ends, Nomenclature of bulbar urethra. This study and evaluation comes from a tertiary high-volume center of reconstructive urology. Apart from our own center's experience the literature was reviewed for evidence synthesis and framing an opinion. Each of the above principles and surgical steps regarding management of pelvic fracture urethral injury was dealt with sequentially and evidence based literature reviewed. Only data from high volume urethroplasty centers and peer reviewed articles which made significant contribution were considered. The data was analyzed and conclusion drawn. On evidence collection there was sparse and scattered evidence in favour of early realignment even after technical advancement. Delayed anastomotic urethroplasty with progressive perineal approach is recommended. Inferior wedge pubectomy cannot be predicted based upon current conventional imaging.The injury and urethral distraction has a wide spectrum and with the fallibility of imaging, inferior pubectomy is a necessary steps under relevant settings to gain access to the posterior urethra. There are multitude of ways to spatulate urethra at either end although literature does not provide a superior way. Spatulation of distal urethra dorsally and leaving the proximal sphincter active urethra unspatulated is be the best scientifically. There is a need to reclassify the bulbar urethra to the penoscrotal junction to avoid under mobilization of bulbar urethra during the repair. There is no conclusive article addressing the controversial issues highlighted in this article. Adequate mobilization of bulbar urethra should be done till penoscrotal junction. Inferior pubectomy as a technique cannot be predicted and its utility cannot be underestimated. The spatulation of urethra can be done in multiple ways. Current anatomical definition of bulbar urethra is erroneous to imply urethra only in the bulb but with respect to surgery it should be extended till the penoscrotal junction.

To evaluate the feasibility of ventral urethrotomy, dorsal inlay (Asopa) technique in management of urethrocutaneous fistula. The Asopa technique has been employed for management of urethral stricture repair but has not been described in adult penile urethrocutaneous fistula. This is a retrospective review of IRB-approved databases of patients undergoing urethral reconstruction from two urologic reconstruction units. In this technique, the fistulous tract is circumscribed and excised, leaving a larger ventral urethral defect with healthy edges. The ventral-sagittal urethrotomy is extended, a dorsal urethrotomy made, and a graft inlaid dorsally to augment the urethral caliber prior to tension-free closure of the ventral urethrotomy. From 2010 to 2019, ten patients underwent repair of urethrocutaneous fistula using the Asopa technique. Median patient age was 33.5 years (IQR 35.5). All fistulae involved penile urethra, eight had concomitant adjacent urethral stricture. Five patients failed prior hypospadias repair, three developed fistulae after surgery for penile urethral stricture, and two developed fistulae after extensive debridement (hidradenitis and Fournier’s gangrene). Of these ten patients, oral mucosa graft was used in nine and preputial graft in one to augment the urethra. At median follow-up of 50.5 months (IQR 26.5), 80% (8/10) of patients demonstrated durably patent urethra, with no recurrence of fistula. The Asopa technique is an established option for augmenting urethral caliber for urethral stricture disease. We demonstrate in our series that this technique can be applied to patients with urethrocutaneous fistulae.

INTRODUCTION AND OBJECTIVE:Failed prior pelvic fracture urethral injury (PFUI) repairs in male patients pose a challenging problem to the reconstructive urologist. These are often scarred, long gap...

INTRODUCTION AND OBJECTIVE:Various technique has been described for the treatment of short non-traumatic bulbar stricture. Of these technique, dorsal onlay buccal mucosa graft (BMG) urethroplasty e...

Urethral stricture is a well-known complication after transurethral surgeries. The incidence of urethral stricture after transurethral resection of prostate (TURP) varies between 2.2 and 9.8%. Most of the cases present within 6 months of transurethral surgery. Presentation is likely with poor flow, urinary tract infection or acute retention. A prospective study was undertaken from January 2010–June 2017 for the management of post TURP stricture. A total of 170 patients with stricture urethra due to TURP were studied. The age of patients was 54–87 years (mean age 67.34). The mean preop Qmax was 6.1 ml (range 0–15). The length of stricture varied from very short in the proximal bulbar to pan urethral stricture. Out of 170, 94 were treated with dorsal approach, 71 with ventral approach and 5 with simultaneous distal dorsal, proximal ventral approach. Five patients underwent endoscopic procedure. Mean BMG length was 6.25 cm (4–8) and width was 1.5 cm (1.3–1.8). Overall success rate was 82.43%. Urethral stricture is a well-known complication after transurethral surgeries. Post TURP can cause stricture at any part urethra. BMG mucosa Urethroplasty is the safe, feasible and offer long-term success in these patient and should be strongly considered over CIC and VIU. Ventral approach is best suited for proximal bulbar strictures close to membranous urethra. This is a continence preserving surgery.

Failed hypospadias includes patients with multiple attempts at hypospadias surgery. These present as recurrent stricture, urethrocutaneous fistula glans dehiscence, urethral dehiscence, chordee, and glans deformity. Failed hypospadias is a complex and challenging issue. Various surgeries and techniques have been described for hypospadias. We need uniform guidelines for management of failed hypospadias. In this paper, we highlight the current and feasible options in the management of failed hypospadias which would deliver best long-term cosmetic and functional outcomes for the patients., Video abstract

Objectives: Pelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios. Methods: Our centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995–2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included. Results: Over two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia. Conclusion: The definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres. Keywords: Urethral reconstruction, Pelvic fracture urethral distraction defects, Pelvic fracture urethral injuries, Bulbar necrosis, Long gap, Bladder neck injury, Rectourethral fistula

The sonourethrogram is a useful alternative to the traditional retrograde urethrogram to evaluate anterior urethral strictures. With the development of 3-dimensional reconstructive techniques 3-dimensional urethral imaging can provide more accurate and useful information to enable the surgeon to make the best surgical decisions. We evaluated the accuracy and efficacy of a 3-dimensional reconstructed digital model of the urethra based on the sonourethrogram to assess anterior urethral disease.A total of 50 patients with an anterior urethral stricture and 10 healthy volunteers were enrolled in this study from April 2014 to January 2017. All patients and volunteers underwent sonourethrogram and retrograde urethrogram. Three-dimensional urethral models were reconstructed based on the sonourethrogram. Stricture length and location on retrograde urethrogram or sonourethrogram based images were compared with those found at operation.The 3-dimensional digital model revealed the entire anterior urethra, including the navicular fossa, and the penile and bulbar parts. The semitransparent model clearly demonstrated the structure of the corpus spongiosum and inside the urethral lumen. Further information on spongiofibrosis could also be seen in the 3-dimensional digital model. There was no significant difference in stricture length or location in the 3-dimensional model compared with retrograde urethrogram imaging and actual surgical findings. However, the latest technique could only reconstruct the short segment of the anterior urethra due to the probe width limitation.The 3-dimensional computerized model based on the sonourethrogram is a novel and effective technique of evaluating anterior urethral strictures.

Urethral stricture disease continues to be a prevalent condition with significant morbidity. Oral mucosal graft augmentation urethroplasty for long segment bulbar urethral strictures is an established management option. Here the authors outline the results of their pilot study designed to evaluate the efficacy of using two innovative steps for graft augmentation.

Background: To lift the neurovascular bundle (NVB) is a critical step during dorsal plications for ventral penile curvature correction. Indeed, this procedure may hesitate in nerves and vascular damage. Herein, we present a revolutionary approach of partial NVB mobilisation that avoids dissection among 10 and 2 o’clock positions decreasing the risk of injuring nerves and vessels. Methods: We assessed ventral penile curvature after penile degloving, marking the level of maximal bending. Bilateral para urethral incisions were made and the Buck’s fascia carefully mobilised from the tunica albuginea. The mobilisation of NVB was carried until 10 and 2 o’clock, avoiding the area between 10 and 2 o’clock positions, where nerves and vessels are more concentrated. The 10 and 2 o’clock positions correspond also to the dorsal edges of the two cavernosa cylinders, where plications are more effective. Penile straightening after surgery was defined as residual curvature less than 10 degrees. Results: Between 2016 and 2020, we have operated 33 men and 32 boys with ventral penile curvature. The severity of penile curvature was mid ( 60 degrees) in 19 (29%) patients. Penile straight was achieved for all patients. We recorded three haematoma, three glans skin erosion, and one curvature recurrence after 13 months of follow-up. No patient reported erectile dysfunction. Conclusion: This proof-of-concept study shows that partial NVB mobilisation is technically easier and safer compared to complete NVB mobilisation, without compromising the success of surgery. Level of evidence: Not applicable

Introduction: Complex penile strictures are usually repaired using a two-stage urethroplasty. Buccal mucosal graft (BMG) placed in the first stage can have a significant contraction rate, which may require a subsequent revision surgery. We describe a composite two-stage penile urethroplasty using BMG for patients of complex penile strictures who have some salvageable urethral plate. Methods: Within a multi-institutional cohort, 82 patients underwent a two-stage urethroplasty for complex stricture of the penile urethra. Of these 42 patients who underwent our composite two-stage penile urethroplasty using BMG implanted at the second-stage were included. Patients with genital lichen sclerosus or incomplete clinical records were excluded from this study. The primary outcome of the study was to evaluate stricture-free success rate. Results: Of total 42, 4 patients were lost to follow-up. 42% of stricture etiology was failed hypospadias repair. Mean stricture length was 4.5 cm (range 3–8 cm). Seventeen (44.7%) patients had undergone the previous urethroplasty. At a median follow-up of 44 months, of 38 patients, 34 (89.5%) were successful, and 4 (10.5%) had a recurrence. No patient required revision surgery before the second-stage and required redo buccal graft harvesting for subsequent urethroplasty. Conclusions: The composite two-stage technique in repairing complex penile urethral strictures is a valid and reproducible surgical treatment for complex penile stricture and it may reduce the rate of contraction of the transplanted BMG.

Anterior urethral strictures include penile, bulbar and panurethral strictures. In the literature various techniques have been mentioned for their management from single stage to two-stage approach. There are no guidelines concerning the use of dorsal or ventral approaches in bulbar urethroplasty. We share our simplified algorithm for the management of anterior urethral strictures. This algorithm is based on the last three decades of experience in urethroplasty and surgeries all around the globe.

Objective Urethral injury occurs in 10% of patients who suffer from pelvic fractures. Urethroplasty is performed after an interval of 3 months to stabilize the perineal hematoma. It has been reported that the rate limiting step in anastomotic urethroplasty is finding the posterior urethra. Even for the most experienced surgeons, at times, this step can be challenging. The aim of the present study was to describe a novel technique for understanding the three-dimensional (3D) anatomy which would also help in surgical planning and making urethroplasty easy, a step ahead of conventional imaging. Material and methods Ours is a tertiary referral center with an experience of >1307 cases of pelvic fracture urethral distraction defects. This study was conducted between January 2018 and July 2018. Ethics approval was obtained. No patients incurred any cost for the study. A computerized tomography scan was performed with the bladder filled with contrast saline, and the same solution was injected into the anterior urethra, with a gauze piece tied around the glans. 3D images were then reconstructed, and data were transferred to the 3D Ultimaker™ printer. 3D models were printed to mimic the anatomy of pelvic fracture urethral distraction. Results A total of 10 models were created. The models, along with conventional urethrogram, were shown to fellows and observers. Visually, they gave a score of 4.3/5. In correlation with urethroplasty, understanding the anatomy of the posterior urethra was also important. Conclusion 3D printing can be applied to pelvic fracture urethral injury to understand the anatomy of the posterior urethra, its distance from the rectum, length of gap, relation to the posterior urethra, direction of displacement of the urethra, and if pubectomy is required or not.

The incidence of pelvic fracture urethral injuries is increasing the world over. Simple cases can be managed locally. However, there are cases which are complex. The management of such cases is challenging and should be done by experts. Recently there have been publications highlighting complex posterior urethroplasty. Our center is a tertiary referral center and we have had the highest number of complex posterior urethroplasty cases published in the literature to date. The referrals are increasing each day. We have categorized complex pelvic fracture urethral injuries into eight scenarios, which we have seen over the last two decades. These scenarios include re- and re-redo cases with multiple prior urethroplasty, bulbar necrosis, boys

The management of panurethral strictures is challenging. Previous literature suggests a two-stage urethroplasty. Panurethral strictures are mostly caused by lichen sclerosus and a two-staged urethroplasty cannot be performed due to recurrence. In this chapter we describe the procedure and main features of a single stage, dorsal onlay, one sided dissection, buccal graft urethroplasty for panurethral strictures.

Posterior Urethral injuries after Pelvic Fracture are one of the most devastating and debilitating situations in Urology. It represents a real surgical and decision-making challenge. The adequate initial and late management to this problem with a multidisciplinary approach could avoid many possible urosexual and orthopedic complications, offering the best results to these patients.

Primary urethral reconstruction for the urethra can be achieved using, free grafts, pedicled flaps and anastomotic urethroplasty. This can be particularly challenging in patients with complex long segment posterior urethral strictures with previously failed repairs and significant scarring. Bulbar Urethral necrosis is the ischemic loss of bulbar urethra after multiple failed surgeries. Few patients land up with a very long gap which cannot be bridged by routinely available techniques. In this chapter we discuss the role of urethral substitution using bowel segment.

INTRODUCTION AND OBJECTIVES:There are no published cases of anastomotic urethroplasty in children less than one-year of age. Boys with a high imperforate anus have a recto urethral fistula. They ar...

Introduction: Repair of post-TURP sphincter urethral strictures represents challenging problem, due to the risk of urinary incontinence after the repair. We described a surgical technique we use to repair these strictures preserving urinary continence in patients with incompetent bladder neck. Materials and methods: An observational, retrospective, study was conducted to include patients with post-TURP urethral strictures in the area of distal sphincter. We included only patients with complete clinical data and follow-up who previously underwent TURP or HOLEP or TUIP, and subsequently developed proximal bulbar urethral strictures close to the membranous urethra and the related distal urethral sphincter. Patients were included, if they were fully continent after TURP or other procedures to treat BPH. The primary outcome of the study was treatment failure, defined as the need for any post-operative instrumentation. Secondary outcome was post-urethroplasty urinary continence. Patients showing stricture recurrence or post-operative incontinence were classified as failure. Results: Overall, 69 patients were included in the study. Median patient’s age was 67years; median stricture length was 4cm. Thirty-tree patients (47.8%) underwent previous urethrotomy. Median follow-up was 52months. Out of 69 patients, 55 (79.7%) were classified as success and 14 (20.3%) as failure. Out of the whole cohort, thus, 11/69 (16%) have a risk of recurrent strictures and 3/69 (4.3%) have incontinence. Conclusions: The use of modified ventral onlay graft urethroplasty, using particular non-aggressive steps, is a suitable surgical technique for repair of sphincter urethral stricture in patients who underwent BPH transurethral surgery, using different procedures (TURP, HOLEP, TUIP).

Introduction and Objective. The proper evaluation of urethral strictures is an essential part of the surgical planning in urethral reconstruction. The proper evaluation of the stricture can be challenging in certain situations, especially when the meatus is involved. We propose that the use of a small caliber ureteroscope (4.5 Fr and 6.5 Fr) can offer additional help and use for the surgical planning in urethroplasty. Methods. We prospectively collected data on 76 patients who underwent urethroplasties in Kulkarni Reconstructive Urology Center, Pune, India and Thunder Bay Regional Health Sciences Center, Thunder Bay, Canada. Patients had retrograde and micturition urethrograms performed preoperatively. The stricture was assessed visually using a 6.5 Fr ureteroscope. If the stricture was smaller than 6.5 Fr, we attempted using the 4.5 Fr ureteroscope. In nonobliterated strictures, we attempted bypassing the stricture making sure not to dilate the stricture. A glide wire would be passed to the bladder under vision. Stricture length, tissue quality, presence of other proximal strictures, false passages, and bladder tumors or stones would be assessed visually. If the penile stricture was near obliterative (smaller than 4.5 Fr caliber), a two-staged procedure is elected to be performed. For proximal bulbar strictures, if the urethral caliber is less than 4.5 Fr and the stricture length is less than 1 cm, we perform a nontransecting anastomotic urethroplasty (NTAU). If the stricture length is >1 cm, we perform a double-face augmented urethroplasty (DFAU). If the urethral caliber is >4.5 Fr and particularly those who are sexually active, ventral inlay with buccal mucosal grafts (BMGs) is performed. In mid to distal bulbar strictures, if the urethral caliber is >4.5 Fr, our procedure of choice is dorsal onlay with BMG. For those with urethral caliber Results. Urethroscopy was performed in 76 patients who presented for urethroplasty from July 2014 to September 2014 (in Pune) and between April 2016 and September 2017 (in Thunder Bay). Bypassing the stricture was achieved in 68 patients (89%) while it was unsuccessful in 8 patients (11%). In all unsuccessful urethroscopies, the stricture was near obliterative Conclusion. The use of the small caliber ureteroscope can help in evaluation of the stricture caliber, length, and tissue quality. The scope can also aid in placing a guide wire, evaluating the posterior urethra, and screening for urethral or bladder stones. It can also improve the preoperative patient counselling and avoid unwanted surprises.

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.

Objective The use of methylene blue dye (MB) to highlight anatomical structures in urology has been well-established. Urethral stricture may extend about a centimeter beyond the abnormal area seen on urethrogram. Although the current literature suggests a tension-free and end- to- end anastomosis after excision of the strictured urethral segment with spongiofibrosis and surrounding corpus spongiosum in short bulbar strictures, some centers dealing with urethroplasty prefer anastomosis for short bulbar strictures while others prefer augmentation. With this study, use of MB for delineating stricture line and assessing spongiofibrosis in the diagnosis of urethral stricture was evaluated. Material and methods Five cc MB including 10 mg/mL is diluted with 10 cc saline. In the first scenario, MB is gently injected into urethra via the meatus before the urethroplasty procedure. Meanwhile, the extent of urethral segment stained by MB is noted. In the second scenario (MB spongiosography) in short bulbar stricture, insulin needles are inserted in spongiosa of the stricture site distally and proximally. MB is gently injected with distal needle. The two remaining needles are then observed. Presence of MB efflux in proximal needle implies deficiency of significant spongiofibrosis, so buccal augmentation is performed. Absence of efflux of MB implies significant spongiofibrosis and anastomotik site excised. Results Four hundred and ninety-two consecutive cases prospectively evaluated between 2010 and 2014. Precise staining of stricture was successfully observed in 464 (94%) patients. Grossly normal appearing urothelium remained pink. Histopathology confirmed that the stained urethra had a stricture. Of the 22 short bulbar idiopathic strictures, in 18 (82%) MB was seen across the stricture and urethral transection was avoided. Anastomosis was performed in 4 (18%) cases where no MB went across the primary excision. There were no known allergic complications. Conclusion MB aids in delineating the urethral lumen and exact site of stricture that needs augmentation. MB Spongiography in short bulbar strictures could be used as a beneficial guide in relation to the type of urethral repair to be performed in terms of augmentation versus excision and anastomosis.