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Ventral playin
1. VENTRAL APPROACH
• The ventral approach is:
Easier
Quicker
Less aggressive &
Versatile
2. EASIER
• Easy to TEACH and easy to LEARN.
• Much easier in:
Very tight strictures.
After a failed urethroplasty or radiotherapy.
Obese patients, and
Proximal bulbar strictures (dissection is difficult).
3. Easier cont.
• Provides a direct access to the
urethral lumen.
• Allows for clear visualization of the
stricture edges which helps a
water-tight graft anastomosis.
These advantages are very clear with
more proximal bulbar strictures
4. • Armenakas 2004 ventral Approach requiring less
urethral dissection and mobilization and is
technically easier.
• Wessells 2002 ventral approach avoids complete
circumferential mobilization of the bulbar urethra,
preserving arterial and venous connections to CC.
Easier cont.
5. Less aggressive
• Allowing the preservation of as much as possible
of the urethral plate during the urethral
Opening. (Palminteri et al 2013).
• Spares bulbar arteries and erectile function.
(Barbagli et al 2005).
6. • Avoids the difficult dorsal urethral mobilization in
scarred urethras, that could cause urethral
ischaemia and disrupt the membranous
sphincter (proximal lesions).
In dorsal inlay: the space for grafting is created
without lifting the two urethral halves from CC,
and saved circumflex and perforators.
Less aggressive cont.
7. • Minimal risk of bleeding/vascular damage
(Palminteri et al 2013)
- In most cases bleeding is easily controlled.
- There are no studies confirming these risks.
Less aggressive cont.
8. Versatile
• It allows the surgeon to choose IN SITU the most
adequate technique for his repair (depending on
the quality of urethral plate).
• Ventral onlay grafting.
• Dorsal inlay grafting.
• Two-sided double grafting.
• Transecting and graft augmented repair.
• Perineostomy (two stage procedure).
9. • In a meta-analysis (24 studies) Mangera et al
2011, reported a surgical success rate of 88.9%
with ventral approach for a mean follow-up of
34.3 months.
This is attributed to the thick and robust spongiosum
tissue ventrally that provide mechanical and vascular
support to the graft.
Excellent outcome
10. Palminteri et al 2013 assessed the impact of ventral
approach on sexual functions and reported:
• Most of the patients noticed a significant improvement in
overall sexual function and (QOL) and were satisfied with
the outcome of urethroplasty.
• Increasing age and preoperative erectile dysfunction are
responsible. (Anger et al 2007)
Improved sexual function
11. To overcome Post-void and ejaculation dribbling:
• Careful midline opening of the bulbospongiosus muscles.
• Preservation of the nerve branches laterally.
• Avoidance of perineal central tendon sectioning.
• Good Packing of the graft with the spongiosum.
• Careful reconstruction of the bulbospongiosus muscles.
• Muscle sparing approach.
Technical tips
12. • Same outcome in much easier approach.
Vasudeva et al 2015 in a prospective randomized study
comparing ventral Vs dorsal approaches concluded that
either techniques have comparable efficacy and
complication rates.
• Requires considerable surgical skill and expertise
to dissect (Palminteri et al 2013)
Why not dorsal approach
13. • Will damage the bulbar arteries and erectile
function when dissection needed to be very
proximal. (Barbagli et al 2005)
The same author recommended this approach only
for selected medium or distal bulbar strictures
(Barbagli et al 2012).
Why not dorsal approach
14. • Dorsal urethral mobilisation is difficult in
scarred urethras with marked periurethral
fibrosis, and an extensive dorsal dissection
could cause urethral ischaemia.
Why not dorsal approach
15. • In very tight strictures the dorsal approach
often mandates a transecting and graft-
augmented anastomotic technique, and still
the problem of vascular damage remains.
Why not dorsal approach
16. • The wider urethral caliber offered by dorsal
grafting (Barbagli 2009) was not reflected
clinically as the outcome of urethroplasty was
comparable in either approaches. (Vasudeva
et al. 2015)
Why not dorsal approach
