This document provides case summaries of various urological procedures performed by Dr. Amit Kumar Mishra at AIIMS Raebareli. The procedures included direct visual internal urethrotomy for urethral stricture, buccal mucosal graft urethroplasty, perineal urethrostomy, partial penectomy with urethral reconstruction, vaginal flap repair of urethrovaginal fistula, extravesical ureteric reimplantation, Jordan's flap procedure for urethral stricture, hypospadias repair in children and adults, staged urethroplasty, transurethral resection of bladder tumor, and transure

1. VOIDING – A MELANGE FROM INFIRMITY TO
RELIEF
DR AMIT KUMAR MISHRA
ASSISTANT PROFESSOR
DEPT OF UROLOGY

2. DISCLAIMER
• CERTAIN IMAGES ARE GRAPHIC IN NATURE,VIEWER
DISCRETION IS ADVISED
• ALL IMAGES AND VIDEOS USED IN THE PRESENTATION
ARE OF PATIENTS ADMITTED AND OPERATED AT AIIMS
RAEBARELI
• ILLUSTRATIONS ARE FROM STANDARD TEXTBOOKS

3. Voiding of Urine as we all know is a very primal and
physiological human function we rarely pay any
attention to,but if the very same physiology turns
pathological it can literally makes one’s life
miserable.

4. LOWER URINARY TRACT SYMPTOMS
(LUTS)

6. FEMALE URETHRA

7. CASE NO 1
CASE HISTORY
• 46 year old male with C/O voiding LUTS since 1 year.
Past h/o catheterization 1.5 year ago.
• IX : RGU showed 1 cm stricture in bulbar urethra
• Dx: Bulbar urethral stricture
• SX : DIRECT VISUAL INTERNAL URETHROTOMY was
done .

8. RGU (RETROGRADE
URETHROGRAM )
BULBAR URETHRAL STRICTURE

9. VISUAL INTERNAL URETHROTOMY
• Considered Standard treatment for short segment stricture
(less than 2 cm),preferably in Bulbar region.
• Incision/Ablation of stricture transurethrally (12 o’ clock
position)
• Healing by secondary intention
• 60-70 % long term success rate.

10. SURGERY/PROCEDURE
INCISION AT 12 ‘O’ CLOCK

11. CASE NO 2
CASE HISTORY
• 22 year old patient presented with history of Voiding LUTS since 3
years,insidious in onset and gradually progressive,had history of
perineal injury 10 years back.
• O/E- EUM –normal,and no other obvious findings.
• On urethral Calibration- Failed beyond penoscrotal part.
• IX –Patient investigated with RGU and Urethrocystoscopy under Local
Anaesthesia ,and planned for Buccal Mucosal Graft Urethroplasty
under GA with nasal intubation.

12. RGU SHOWING BULBAR STRICTURE

13. URETHRO CYSTOSCOPY SHOWING THE SAME
Showing narrowed lumen and slit like opening in
bulbar urethra

14. BMGU FOR STRICTURE > 2 CM
BUCCAL MUCOSAL GRAFTS (BMG)
• An ideal substitute for the urethra.
• Easy accessibility and manual handling.
• Resistance To infection.
• Compatibility with a wet Environment.
• A thick epithelium and a thin Lamina propria.
• Allowing early inosculation

15. SURGERY
Midline Perineal incision Exposure of Bulbospongiosus muscle

16. STEPS
Incising bulbospongiosus muscle in midline and dissected away from underlying
urethra

17. STEPS
Urethra dissected Urethra lifted up from corpora

18. STEPS
Ventral stricturotomy made Distal limit of stricture
determined
Proximal limit of
stricture

19. BUCCAL GRAFT HARVESTING
-Graft dissected in the plane
between the mucosa and the
muscle
-Ideal graft
• 4 x2.5 cm.
• an ovoid shape,
• 1.5 cm from the Stensen duct
and 1.5 cm from the external
edge of the cheek.

20. Fixation of buccal graft to corporal
bodies
Final closure of the the urethral
lumen
STEPS

21. FOLLOW UP
COMPLETELY HEALED WOUND

22. RESULTS

23. CASE NO 3
CASE HISTORY
• 70 year old male prsented with c/o voiding LUTS which were
progressive in nature since last 10 years.
• Past h/o TURP 12 years ago
• Ix - RGU showed luminal narrowing present from mid penile
urethra to membraneous urethra.
• Sx :Perineal urethrostomy was done
Complex Lengthy stricture

24. URETHROCYSTOSCOPY
Urethra- Luminal narrowing from mid penile urethra to membranous
urethra.

25. PERINEAL URETHROSTOMY
INDICATIONS
• Salvage Procedure.
• Complex Stricture.
• Unfit patients for BMG.
• After Total penectomy
-Patients have to squat to pass urine.
-Usually permanent procedure.
-Stenosis can happen

26. PERINEAL URETHROSTOMY
Raising of inverted U shaped flap in
perineum, Urethra was again dissected
and incised in midline.

27. SURGICAL STEPS
Bulbar urethra dissected and
incised ventrally up to
narrowing, Wide open urethra
Apex of the flap sutured to
bulbo membranous part. ,wide
perineal urethrostomy
made,14 Fr foleys kept,wound
sutured

28. PARTIAL PENECTOMY WITH
URETHRAL RECONSTRUCTION

29. CASE NO 4
CASE HISTORY
• 40 yr old male presented with complaints of growth and bleeding from penis
since 2 years.
• O/E - fungating growth involving whole glans and obstructing urethral
orifice,induration present upto mid shaft region.No palpable inguinal lymph
nodes present
• Ix : Wedge Biopsy for HPE was : suggestive of squamous cell carcinoma .
• Sx : Partial penectomy with urethral reconstruction was done

30. PARTIAL PENECTOMY AND URETHRAL
RECONSTRUCTION
Fungating penile growth Neo urethral meatus formation

31. APPEARANCE AFTER 2 MONTHS
FOLLOW UP

32. URETHRO VAGINAL
FISTULA

33. CASE NO 5
CASE HISTORY
• 32 y/o female presented with complaints of continuous leakage of urine ,soiling of
clothes and a pervading ammoniacal stench leading to great embarrasment and
social stigma
• She had undergone obstructed labour around 3 years before and was having this
problem since then.She was previously evaluated at sgpgi but could not be operated
due to repeated date and monetary problems.
• O/E-- mid urethral narrowing with mid to proximal urethral fistula just distal to
bladder neck where the urinary sphincter in female is found.
• Ant vaginal wall showed a fistulous opening present in connection with urethral
fistulous opening
• Ix :CT scan showed contrast filled track arising from neck of bladder to anterior
vaginal wall.
• Sx : Vaginal Flap repair of urethro vaginal fistula with MARTIUS FLAP

34. CONTRAST FILLED TRACT SEEN ARISING FROM NECK OF BLADDER TO
THE ANTERIOR VAGINAL WALL

35. URETHROVAGINAL FISTULA
During cystoscopy,
guidewire inserted through
the vaginal opening of
fistula can be seen nicely
coming out from urethra
and bladder alongwith the
defect.

36. Vaginal flap repair with maritus flap
Raising of anterior vaginal wall flap Creation of flap between vagina and bladder,
bladder was repaired in two layers (Bladder
wall and Perivesical fascia)

37. Interposition of Martius flap
between vagina and bladder(3rd
layer)
Final closure of anterior vaginal wall(4t
layer)

38. Patient completely free of
disease
Follow up

39. URETEROVAGINAL FISTULA

40. CASE NO 6
CASE HISTORY
• 27 y/o female presented with continuous leakage of urine per vagina along with
voluntary voiding after undergoing abdominal hysterectomy in a private hospital
in April 22 .
• O/E : Continuous uncontrolled copious urine discharge was present per vaginum.
• Ix : CT Urogram –showing massively dilated proximal ureter with complete
obstruction @ the level of ischial spine, RGP showed complete lumen block of the
distal ureter. Vaginoscopy showed the fistula in the posterior fornix.
• Sx : Left extravesical ureteric re implantation with psoas hitch.

41. POST HYSTERECTOMY MEGAURETER
AND URETEROVAGINAL FISTULA
CT UROGRAM –SHOWING MASSIVELY DILATED URETER WITH COMPLETE
OBSTRUCTION

42. RGP – showing complete lumen block
at the level of ischial spine
Vaginoscopy showing the fistulous opening
in the posterior fornix
RGP VAGINOSCOPY

43. EXTRAVESICAL URETERIC
REIMPLANTATION
Ureteric reimplantation and 5/26 DJ stent
was kept
Showing massively dilated ureter
with complete obstruction
accidentally ligated during a
hysterectomy

44. HAPPY PATIENT
ON FOLLOW UP

45. CASE HISTORY
28 year old patient presented with pin point meatus and
difficulty in voiding ,he was about to marry so he sought medical advice
regarding the same.
CASE NO 7

46. JORDAN’S FLAP
• INDICATION
• DISTAL URETHRAL STRICTURE WITH MEATAL
STENOSIS

47. JORDAN’S FLAP
Lateral glans wings dissected.
- Skin island Is then elevated
on dartos fascia.
transposed and inverted
into the remaining dorsal
midline strip
Ventral transverse skin
island .
A urethrostomy defect is
created to the level of
normal urethra
The skin island is
sutured into the
defect.

48. JORDAN’S FLAP
Pin point meatus
Hardly seen
Degloving of penis and raising
of dartos with skin island flap
Final flap raised

49. FOLLOW UP
Final picture after 2 months – showing wide
meatus allowing 14 fr catheter

50. HYPOSPADIAS - CHILD
• MOST COMMON CONGENITAL ANAMOLY OF PENIS.
• Urethral meatus opens on ventral side of penis,proximal to the tip of
penis.
• Presence of excess skin on dorsal side known as hood,and
• Curvature of penis may or may not be present.

51. CASE NO 8
CASE HISTORY
• 2 yr old child presented with
passing of urine from ventrum ,
with complaints of crying while
passing urine.
• O/E - severe meatal stenosis, a pin
point urethral opening could
hardly be delineated.Dorsal hood
present,very narrow urethral
plate,glans tilt.
• Sx - performed a reconstruction
with a mixture of 2 procedures
snodgrass +preputial graft)-
known as snodgraft as urethral
plate was too narrow and thinned
out in distal penile part.

52. HYPOSPADIAS - CHILD
Circumcoronal incision and
degloving of penis
Raising of glans wings

53. HYPOSPADIAS - CHILD
Raising of dartos flap Final result

54. PATIENT DEMONSTRATING GOOD URINARY STREAM POST
SURGERY

55. • HAPPY PATIENT ON FOLLOW UP

56. HYPOSPADIAS - ADULT

57. CASE NO 9
CASE HISTORY
• 30 year old male presented with abnormal position of urethral opening
since childhood, voiding luts and painful erection due to extreme curvature
of penis in erect positon.Patient was about to be married so needed the
consultation.
• Dx- Adult midpenile hypospadias
• Sx – Stage 1 repair with byars flap.

58. ADULT HYPOSPADIAS
Multiple fistulous opening on
ventrum of penis
Dorsal preutial hood and
chordee(curvature) of penis

59. Penile degloving and Gittes
test
Transection of urethral plate
for chordee correction
Stage 1 repair with Byars
flap(Penile shaft skin is
dorsally incised and
wrapped around )

60. STAGED URETHRAL
RECONSTRUCTION
INDICATIONS
• Extensive urethral & peri-urethral fibrosis
• Long segment of obliteration
• Panurethral stricture
• Associated fistula
• Insufficient penile skin/donor tissue

61. CASE NO 10
Case history
42 yr old male presented with severe voiding LUTS and purulent
discharge per urethra since 1 week.
O/E- meatal stenosis,a fluctuant swelling on midpenile shaft,and
purulent discharge per urethra.
Ix : Urethrocystoscopy showed completely destroyed distal urethra with
purulent discharge .Meatal stenosis present.
RGU/ MCU- showing irregular and distal urethral stricture
along with meatal stenosis
Sx : Johanson’s staged urethroplasty.

62. • RGU/MCU- showing irregular and distal urethral stricture
along with meatal stenosis
RGU/MCU

63. Distal urethra –completely destroyed with purulent
discharge and whitish flakes,meatal stenosis present
URETHROCYSTOSCOPY

64. STAGE 1

65. STAGE II URETHROPLASTY
Buccal graft in glanular
,part of urethra with closing
of the neourethra
2 layer closure of neourethra with dartos and penile skin

66. TRANS URETHRAL RESECTION
OF BLADDER TUMOUR

67. CASE NO 11
CASE HISTORY
• 65 year old male patient presented with on & off hematuria , dysuria
passing of clots-leading to voiding LUTS since last 1 year
• Was diagnosed as BPH WITH UTI outside and treated with alpha blockers
• IX :But symptoms persisted so evaluated at Aiims with CECT abdomen
and pelvis suggestive of growth of bladder near Rt VUJ.
• On urethrocystoscopy polypoidal growth seen arising from bladder
encasing whole Rt VUJ.
• Sx : Transurethral resection of bladder tumour was done and specimen
sent for HPE.

68. USG KUB
Nodular thickening at Right VUJ

69. CECT RECONSTRUCTION
CECT : Abdomen and pelvis suggestive of bladder mass
near Right VUJ.

70. TRANSURETHRAL RESECTION OF
BLADDER TUMOUR - SURGERY
HPE : Superficial growth :low grade urothelial carcinoma with focal
high grade areas
Deep muscle :free of tumour

71. TRANS URETHRAL RESECTION OF
PROSTATE

72. CASE NO. 12
CASE HISTORY
• 68 year old male presented with chief complaints of severe voiding
LUTS since 4 years .
• IX : On USG he was found to have high post voidal residual urine
volume (170 ml) and a large median lobe of prostate (40)
producing voiding symptoms.
• Diagnosis of BPH with voiding LUTS was made and patient
planned for TURP.
• Sx : TURP was done.

73. TURP
Very large median lobe of prostate obstructing whole of bladder neck
Median lobe resection followed by bilateral prostate lobe resection
Creation of wide open prostatic fossa.

74. CURRENT STATUS @ AIIMS RAEBARELI
• ADDITIONAL OT DAY IS THE NEED OF THE HOUR
TO MEET WITH THE OVERWHELMING DEMAND
OF PATIENTS REQUIRING SURGERY. 4 EXTRA
DAYS IN A YEAR IS JUST NOT ENOUGH.
• C- ARM IS REQUIRED FOR RENAL STONE
SURGERY .
• RIRS – LASER ACQUIRED ,FLEXIBLE SCOPE IS YET
TO BE RECEIVED
PROCEDURE CAN BE STARTED AS SOON AS FLEXIBLE
SCOPE IS RECEIVED.

75. THANK YOU!!!