The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures. Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries. Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.

2. Objective
Principles
 History
 Definition
 Diagnosis
 Basic principle for urethroplasty
 Current recommendation for urethroplasty
Practices
 Which technique to choose
 How BMG is applied in different technique
 Medium term / long term success
 What is the future

3. Epicurus, a Greek philosopher,
was known to commit suicide
when he could no longer dilate his
own stricture

4. History
 Development of the Duplay-Denis Browne principle, buried, ventral
or dorsal, strip of oral mucosa becomes an epithelialized tube.
 In 1980, Monseur fully applied Duplay’s principle and described the
first dorsal urethroplasty.
 opening the dorsal urethral surface and fixing the opened urethra over the underlying corpora cavernosa, and
leaving a catheter in place for a long period
 Devine and collaborators popularised the use of genital and extragenital
free skin grafts for urethral reconstruction

5. History
 Barbagli
 Combined Devine’s technique with Monseur’s and described a new technique
for dorsal onlay graft urethroplasty

6. History
 First described at the end of the
19th century by the Russian
surgeon Kirill Sapezhko (1857–
1928)
 He published his experience of
four cases of urethral stricture
disease treated in men using oral
mucosal grafts in the Russian
medical journal Chirurgicheskaya
letopis
Sapezhko KM. To the treatment of urethral defects using mucosa grafts [in Russian]. Chirurgicheskaya letopis 1894;4:775–84.
Vasiliyev KK. K.M. Sapezhko—the professor of Novorossiysk University

8. Blood supply

10. Modern History of Urethroplasty by Anatomical Segment
Anterior Urethra
Penile Urethroplasty
• 1953: Johanson staged urethral repair without grafting
• 1999: Hayes and Malone OMG dorsal inlay technique for hypospadias
• 2001: Asopa one-stage OMG dorsal inlay urethroplasty in adults
Bulbar Urethroplasty
• 1996: Barbagli dorsal onlay OMG bulbar urethroplasty
• 1996: Morey and McAninch harvest technique of OMG and OMG ventral onlay urethroplasty
• 1998: Webster augmented dorsal graft anastomosis
• 2006: Barbagli fibrin glue urethroplasty
• 2008: Barbagli bulbospongiosus muscle and nerve sparing bulbar reconstruction

11. Pan-urethroplasty
• 1953: Johanson two-stage urethroplasty: penile ventral marsupialization followed by
second stage retubularization 6 months later
• 1993: McAninch distal/preputial circular fasciocutaneous skin flap
• 2000: Kulkarni penile invagination technique with OMG dorsal onlay
• 2009: Kulkarni one-sided penile invagination technique to preserve lateral neural and
blood supply to urethra
• 2010: Barbagli supported perineal urethros- tomy with Blandy flap technique for
complex/ irreparable urethral strictures or unfit patients for surgery

12. Posterior Urethra
• 1962: Pierce total abdominal pubectomy for exposure of posterior urethra
• 1968: Paine and Coombs end-to-end anasto- mosis after resection of scar and pubic bone (abdominal approach)
• 1973: Waterhouse combined abdomino-peri- neal approach.
• 1976: Turner-Warwick use of omentoplasty for transpubic primary anastomosis.
• 1986: Webster and Goldwasser perineal anas- tomotic urethroplasty with infrapubectomy.

13. Definition
 Urethral stricture refers to urethral
luminal narrowing with associated
spongiofibrosis, which occurs in the
anterior urethra (distal to the external
sphincter).
 Urethral stenosis is an obliterative,
fibrotic process that occurs in the
posterior urethra or bladder neck, usually
secondary to pelvic fracture urethral
distraction (PFUD) injuries or surgery
such as radical prostatectomy

14. Principles true hybrid of urologic and plastic surgery
 Do no harm
 Urethral tissues are very delicate and improper handling may lead to further
damage and compromised tissue quality
 The tissue planes must be respected, and meticulously dissected layer by layer
 Hemostasis must be quick and precise
 Bipolar cautery is preferentially used
 Proper visualization is key
 Good retractor
 Surgical loupes
 Proper lighting and
 Knowledgeable surgical assistant

15. Urethral Anastomosis Principle
(1) tension-free
(2) watertight
(3) well-vascularized tissue
(4) Stented urethral anastomosis
using
(5) Resorbable sutures.

16. RUG + MCUG
 Modified lateral decubitus
position,
 Hips placed at a 45° angle
 Lower leg bend and the upper
leg straight
 Penis must on full stretch
 Patient is in a correct oblique
position, only one obturator
foramen should be visualized on
the scout image.
(a) Scout film and (b) retrograde urethrogram
showing a bulbar urethral stricture
• assess the continuity of urethra
• length of gap between the proximal and distal ends
• State of bladder, presence of diverticulum, stones
• bladder capacity
• Bladder neck—open or closed

17. Urethral Rest
 For anterior urethral
strictures, the urethra
should not be instrumented
for 6–12 weeks prior to the
urethroplasty.
 This allows the scar to
mature and declare itself
appropriately

18. Pelvic fracture urethral defect
[PFUD]
 Should undergo a preoperative examination
under anesthesia, as estimation of the length
of the defect requires an antegrade flexible
cystoscopy via their suprapubic cystotomy
site, while a RUG is performed
simultaneously
 Recommend repeat imaging after the
period of urethral rest as the surgical
plan may differ once the stricture has
fully declared itself
 Pre-operative urine culture performed

19.  For PFUD, a 3-month period of urethral rest is
traditionally recommended
 although recent data has shown that a 3–6-week
resting period has similar outcomes.
 Reconstructive urologist must ensure that
 Patient’s other injuries have been appropriately
addressed
 Patient is physically able to be placed in the

20. Surgical Equipment
 Surgical loupes
 Headlight
 Scissors..
 Retractors

21. EAU 2021

22. Nontraumatic bulbar strictures
 Site of graft does not alter the outcomes for bulbar urethroplasty (LE-3, GR-strong)
 In obese patients, young sexually active and post-TURP proximal bulbar
strictures ventral onlay urethroplasty remains the first-choice (LE-5, clinical principle)
 Proximal bulbar strictures with healthy, spongiosa ventral onlay urethroplasty
is the first choice procedure (LE5, clinical principle)
 Dorsal approaches include Barbagli-Circumferential mobilization or Kulkarni-
One side dissection for dorsal onlay and Asopa for Dorsal inlay (LE3, GR
moderate).
Kulkarni, et al.: USI guidelines on urethral stricture

23. Traumatic bulbar strictures
 There is no role for DVIU (LE-3, GR-strong)
 Short stricture-excision with anastomotic urethroplasty
(LE-3, GR strong)
 Long stricture/failed anastomotic -Augmented
anastomotic urethroplasty is recommended (LE 4, GR strong).
Kulkarni, et al.: USI guidelines on urethral stricture

25. The procedures of
urethroplasty
Anastomotic urethroplasty
(EPA)
Substitution urethroplasty
in which a free graft or a
flap of substitute material
is interposed

26. Define the term:
 Augmentation Urethroplasty
 Substitution Urethroplasty
 Augmentation anastomotic urethroplasty

27. Why BMG?
 Cosmetically superior incision
 Hairless
 Decreased operative time
 Accustomed to a wet environment
 Resistance to infection,
compatibility with a wet
environment
 has a thick epithelium and a thin
lamina propria, making it tough and
easy to handle -----encourage graft
imbibition and inosculation
LONG-TERM FOLLOWUP OF THE VENTRALLY PLACED BUCCAL MUCOSA ONLAY GRAFT IN BULBAR URETHRAL
RECONSTRUCTION SEAN P. ELLIOTT, MICHAEL J. METRO AND JACK W. MCANINCH

28. Technique of graft selection
 Harvest a rectangular graft that was
20% longer and 15% wider than the
urethral defect in order to
compensate for spontaneous elastic
retraction.
 Care was taken to avoid damage to
the orbicular muscle and, to the
Stensen’s duct, the facial nerve and
the buccinators muscle.

32. Anesthesia
 Nasal intubation is not
mandatory, but it is helpful for
surgeons who are not familiar
with this technique.

33. Urethroscopy
 attempted with a 6Fr
pediatric cystoscope / URS
in all patients.
Warner JN, Malkawi I, Dhradkeh M et al. A multi-institutional evaluation of the management and outcomes of
long-segment urethral strictures. Urology 2015; 85: 1483–7.

34. Selection of technique
 In the bulbar urethra, the surgical technique selected
 Stricture length
 Stricture aetiology
 Density of the spongiofibrosis tissue

35. Why EPA?
 Urethra is the best substitute
for urethra - Turner- Warwick’s
opinion is still true
Indication
Penile: sharp cut
Bulbar: Traumatic
Posterior: Progressive perineal approach

36. Pillars of a successful anastomotic urethroplasty
 An adequate urethral
mobilization without
tension
 an excision of scar tissue
 a precise mucosa
approximation

37. Advantage of EPA
 Urethral reconstruction with excision of the strictured area
and end-to-end anastomosis is successful in >95% of
patients with a stricture of<2 cm
 Webster GD Et al.

38. EPA: Disadvantage
 Compared with BMG patch techniques EPA has
 penile curvature (36% vs. 8%)
 penile shortening (38% vs. 11%)
 impaired erection (79% vs. 15%)
 impaired sexual life (57% vs. 19%)
 Overall satisfaction about sexual life was 74% vs
97%
Eltahawy EA, Virasoro R, Schlossberg SM, McCammon KA, Jordan GH. Long-term followup for excision and
primary anastomosis for anterior urethral strictures. J. Urol. 2007; 177: 1803–6.

39. EPA disadvantage
 Success outcome in urethral repair should be
assessed not only by objective voiding parameters
but also by subjective parameters influencing
satisfaction
Culty T, Boccon-Gibod L. Anastomotic urethroplasty for posttraumatic urethral stricture: previous
urethral manipulation has a negative impact on the final outcome. J. Urol. 2007; 177: 1374–7.

40. Substitution Urethroplasty
 Substitution urethroplasty is therefore the procedure of
choice for a long stricture in the proximal bulbar
urethra or a stricture of any length located anywhere
from the distal bulbar urethra to the penile urethra.

41. 3 Options of one stage
urethroplasty
(i) an onlay augmentation procedure (incise the stricture
and carry out a patch augmentation)
(ii) an augmented anastomotic procedure (excise the
stricture and restore a roof of the floor strip of native
urethra augmented by a patch)
(iii) a tube augmentation (excise the stricture and put in a
circumferential patch)

44. Rationale for dorsal graft
 The corporeal body is a healthy host
for graft
 Graft fixation by decrease graft
shrinkage and sacculation
 Ventral urethral opening may create
serious bleeding from particularly
thick and highly vascular spongy
tissue
 Periodic stretching during erection,
thereby reducing the risk of patch
retraction
Andrich DE, Mundy AR. Substitution urethroplasty with buccal mucosal-free grafts. J Urol
2001;165:1131–3.

45.  Dorsal Onlay Augmentation Urethroplasty 1996
Barbagli`s Technique

46. Barbagli`s Technique

47. Barbagli`s Technique

48. Barbagli`s Technique

49. Disadvantage of dorsal technique
 Extensive mobilization of the urethra is necessary
 Surgical technique is more difficult
 Operation time is longer
 Ischemic damages secondary to the dissection is higher

50. Success rate
 Dorsal onlay BMG urethroplasty has shown a
success rate from 87.5% to 100% with a follow-up
ranging from 22 to 41 months .
24. Metro MJ, Wu HY, Snyder HM 3rd, Zderic SA, Canning DA: Buccal mucosal grafts: lessons learned from an 8-year experience. J Urol. 2001; 166: 1459- 61.

51. Success rate
 Barbagli et al., published a retrospective study of 50
cases with bulbar urethral stricture
 Grafts were placed as ventral, dorsal and lateral onlay
in 17,27 and 6 patients respectively
 After a mean follow-up of 42 months, showed the
similar success rate

52.  Ventral Onlay Augmentation Urethroplasty
Techniques first
described by Morey and
McAninch in 1996 for
bulbar urethral strictures

53. Ventral onlay: Advantages
 Limited urethral mobilization with preservation of
perforating arteries
 Shorter operative time and easier technique
compared with the dorsal onlay procedure
 Simple technique and the phases of imbibition and
inosculation are facilitated

54. Ventral onlay: Disadvantage
 Carried out only for midbulbar and proximal bulbar
strictures
 Not suited for traumatic bulbar urethral stricture severely
scarred corpus spongiosum
 Lack of spongiosum support reduces the likelihood of graft
survival, and increases the risks of ballooning and urine
pooling.

59. Tips ventral placement
 The use of a larger caliber catheter has the advantage of
exposing the entire graft surface to the recipient bed
provided that no tension on the sutures is exercised

60. Lateral Onlay Augmentation
Urethroplasty

61.  Kulkarni`s Dorsolateral onlay
procedure 2000

62. Advantages
 Avoiding excessive circumferential mobilization of
the urethra reduces the vascular damage occurring
during urethroplasty.

63. One-sided dorsolateral onlay (Kulkarni technique)
 Done for complex panurethral strictures
 Kulkarni et al. reported an excellent result of a one-
stage procedure by dorsolateral onlay: with a
median follow up of 59 months the overall success
rate was 83.7%.62

68. Dorsal Inlay Augmentation Urethroplasty
Asopa`s technique

69. Advantages: Asopa technique
 Eliminates the outpouching and ballooning of the graft
 The two halves of the urethra derive their blood supply
from the circumflex and perforating vessels
 The sizing of the graft is accurate and hence pooling of
urine and semen is minimized.
DORSAL FREE GRAFT URETHROPLASTY FOR URETHRAL STRICTURE BY VENTRAL SAGITTAL ·uRETHROTOMY APPROACH HARi S. ASOPA, D , LAKHAN SOTI ASOPA

70. Limitations : Asopa`s technique
 The urethral plate needs to be more than 1 cm wide
 The graft that can be inlayed is typically narrower
than the wide grafts that can be achieved with an
onlay procedure

72. Obliterative stricture
 In obliterative or nearly
obliterative segment
 Neither EPA nor an onlay
procedure is possible, because
such a stricture contains a
significant amount of
spongiofibrosis
 Length of excised urethra would
result in too much tension on
anastomosis

73. Options for obliterative
 Combination of EPA and primary anastomosis and
onlay augmentation, a combination called an
augmented anastomotic urethroplasty.
 Onlay augmentation using two grafts (two-sided
dorsal plus ventral onlay urethroplasty, Palminteri
technique
Palminteri E, Lumen N, Berdondini E et al. Two-sided dorsal plus ventral oral graft bulbar urethroplasty: long-term results and predictive factors. Urology 2015; 85: 942–7.

74.  Combined Dorsal plus Ventral Double Buccal Mucosa
Graft in Bulbar Urethral Reconstruction
Palminteri
technique

75. Palminteri technique

76. Palminteri technique

77. Palminteri technique

78. Palminteri technique

79. Palminteri technique

80. Palminteri technique

81.  In 2001, Guralnick and Webster introduced the term
“augmented anastomosis”
 Most obliterated segment of the stricture is excised, and
stricturotomy is carried out
 Either the ventral or dorsal wall is then anastomosed, and the
remaining defect on the other side is repaired with a graft
 They also suggested that strictures longer than 5 cm are
amenable to repair using this technique

82. Augmented anastomotic
urethroplasty

84. Graft failure
 Graft failure at the proximal anastomosis attributed to under
staging disease during surgery.
 Proximal anastomosis is deep in the bulb, which is a more
difficult site technically in which to ensure epithelium-to-
urothelium placement.
 Further study is necessary to clarify the true etiology of this kind
of repeat structuring (ischemia, suture line or suture material),

85. Graft failure
 Early failure of a free graft can result from a poorly vascularized recipient bed
or infection hematoma.
 Late re-stricture may owe to progression of the original disease.
 Grafts fare poorly in the pendulous urethra where the corpus spongiosum is
less vascular.
 Graft failure at the distal anastomosis may represent poor inosculation owing
to poor graft bed vascularity.
 Important to incise the urethra well into normal tissue proximally and distally
to ensure complete stricture incision

86. Case of graft failure
 remains uncertain …..poor healing and graft
incorporation at one or other end of the patch.
 poor graft ‘take’, deficient vascularity of the graft bed,
poor surgical placement of apical sutures, or
insufficient dissection proximal and distal to the
stricture site to expose normal
 Other series suggested that most failures occur in the
first year, implicating technical operative errors ,
whereas the present data suggest a peak at 2 years
Andrich DE, Dunglison N, Greenwell T, Mundy AR. The long-term results of urethroplasty. J
Urol 2003; 170 : 90–2

87. Complication of BMG
 Urethrocele with post-void dribbling
and semen sequestration are
common
 Yucel and Baskin reported that
 perineal nerves innervate the
bulbospongiosus muscles and
send fine branches to penetrate
the corpus spongiosum, muscles in
the midline.
 Rhythmic contractions of the
bulbospongiosus muscles and
other perineal muscles expel
semen and from the urethra

88. Recurrence
 Stricture recurrences can, however, occur despite using
an adequate surgical technique and substitution
material may deteriorate over time
 Armenakas NA. Long-term outcome of ventral buccal mucosal grafts for anterior urethral
strictures. AUA News 2004;9:17–8.
 Elliot SP, Metro MJ, McAninch JW. Long-term followup of the ventrally placed buccal
mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754–7.

89. Recurrence
 After bulbar substitution onlay urethroplasty
 Extensive fibrous tissue involving the entire grafted area or
 Short fibrous ring stricture at the distal or proximal anastomotic
sites
 Use of fibrin glue in a new technique of dorsal onlay buccal
mucosal graft urethroplasty to
 reduce the time of postoperative catheterisation,
 the risk of postoperative urinary leakage, and
 to reduce the incidence of postoperative anastomotic rings at the
apices of the sutures between the graft and the mucosal urethral
plate

90. Glue
 The application of fibrin glue in urology mainly relates
to
 Sealing power
 Adjunct to sutures for closing wounds and promoting
healing because it increases tissue plane adherence,
accelerates revascularization,
 Reduces haemorrhage, prevents seroma formation, and
decreases inflammation
22] Hick EJ, Morey AF. Initial experience with fibrin sealant in pendulous urethral reconstruction. Is early catheter removal possible? J Urol 2004;171:1547–9.

91. DVIU after BMG
 Well-vascularized grafted area usually develops a
short and soft stricture, which responds better to
incision than primary strictures surrounded by
abundant scar tissue

92. Stage urethroplasty
 The diseased corpus spongiosum is excised and proximal
urethrostomy is performed.
 The dartos fascia is then sutured in the midline and buccal
mucosal grafts are spread fixed onto the corporeal bodies.
 The patient is discharged home between postoperative days
8 and 10 after ensuring graft take.
 Stage 2 urethroplasty is performed after 6 months

93. Required volume
 Low-volume surgeons that the learning curve is long
and never reaches a plateau, even after 20 years.
 (at least 15 cases a year) could treat bulbar urethral
strictures in less specialized centers.
Figler BD, Malaeb BS, Dy GW, Voelzke BB, Wessells H. Impact of graft position on failure of single-stage
bulbar urethroplasties with buccal mucosa graft. Urology 2013; 82: 1166–70.

94. Future
 With the advent of tissue
engineering, artificially
produced grafts might also
find a place in the arsenal
of the reconstructive
surgeon.

95. Conclusion
 “primum non nocere” (“first, do no harm”)
 Currently the best technique is probably the one with
which the urological re-constructive surgeon is most
comfortable

96.  Thank you