Monday, January 22, 2007

Surgical tips for Urethroplasty - Dr.’s Hwang Choi from South Korea and Katsuya Nonomura from Japan chaired the instructional course focusing on surgical tips for urethroplasty. The faculty included Gerry Jordan from Norfolk Virginia, Wachira Kochakarn from Thailand, Jack McAninch from San Francisco, and Christopher Chapple from The UK.The session started with Dr. Kochakarn’s discussion on the surgical management of female urethral diverticulum. The incidence of a urethral diverticulum is 1.4 - 7% in women aged 35-40 years. The classic three presenting symptoms of dysuria, dyspareunia and post void dribbling are common but the presentation can be complex with recurrent urinary tract infections being the presenting complaint in 32-52% of women. The diagnosis of the condition is still largely by physical exam with 61% of patients having anterior vaginal wall masses with or without urethral stripping. For cases with absent physical exam findings but a high index of clinical suspicion, there is data to support the use of VCUG (sensitivity of 44-93%) and or pelvic MRI or CT. Urodynamic assessment should be performed on all women with symptoms of urinary incontinence. The surgical tips detailed the importance of keeping the periurethral fascia intact during dissection, avoiding overlapping suture lines, and utilizing Martius flap coverage if needed.Chris Chapple then lectured on first-time urethroplasty. He began his discussion about terminology and stressed that posterior urethral strictures should be more properly referred to as pelvic fracture urethral distraction defects. He discussed important aspects of diagnosis and stressed that urinary flow rates will not be diminished until the urethral lumen has narrowed to 11 Fr. With this in mind, he feels that flexible urethroscopy should be used both pre-operatively for diagnosis and post-operatively for assessment of surgical outcomes. He quoted some sobering success rates for incisional urethrotomy with long-term success rates for short bulbar strictures 50% which falls to 10% for second urethrotomies and virtually 0% for subsequent attempts. He advises urethroplasty as primary therapy for traumatic posterior distraction defects and after one endoscopic failure for all other strictures. Dr. McAninch described the use of flaps in urethroplasty surgery. He started with the basics of defining grafts- which rely on the surgical bed for blood supply- and flaps which bring their own blood supply. He then described in detail the circular fasciocutaneous flap which has been a mainstay in his surgical armamentarium for the treatment of penile or pendulous urethral strictures. The flap is raised via two parallel subcoronal incisions 2.0 to 2.5 cm apart. The dorsally-based pedicled flap is dependent upon the superficial lamina of buck’s fascia. The flap is developed, split ventrally and rotated around the penis and anastomosed to the dorsal urethral plate in a running fashion. The flap is very adaptable and can be used anywhere along the urethra and can be combined with other tissue transfer techniques (such as buccal mucosa) to allow for total urethral substitution.Finally, Gerald Jordan discussed salvage urethroplasty. When dealing with re-do’s and extremely poor native urethral tissue, bringing new tissue in, such as split-thickness skin grafts, buccal mucosa and penile flaps, are extremely important. Both one-stage and two-stage repairs were described. These techniques are not for the casual urethral surgeon and require experience and expertise that has not been acquired by many.
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