Management of urethral distraction injuries

Sanjay Balwant Kulkarni

Center for Reconstructive Urology Pune, India.

Management of the patient with

urethral injury

Resuscitate the Patient to save life

Supra Pubic Catheter

Preserve the bladder neck

Avoid jeopardizing sexual function

residual to the trauma

Open surgery

•  Abdominal trauma- Laparotomy

•  Bladder injury- Repair •  Bladder neck injury- Repair •  Rectal injury- Colostomy

Urethral trauma

Emergency- Supra Pubic Catheter Stable patient- ? Endoscopic Realignment 3 months - Anastomotic urethroplasty

Bulbar urethral strictureTraumatic!

< 2 cm! > 2 cm!

End-to-end ! Augmented !Anastomosis!

DVIU!Two stage!

1 - 2 cm Traumatic bulbar urethral stricture

Spatilation: Proximal-Perineal Distal-Dorsal

Dorsal wall: Single layer Ventral wall: Two layer

2 - 4 cm Traumatic bulbar urethral stricture

Augmented anastomotic repair

Injury -Posterior urethra plucked away Surgery -Bulbar urethra mobilized

MCU+ RGU

Bladder Neck closed Bladder Neck opened

Bulbo-prostatic gap Bulbar urethral length

Less than 1/3 Less chance of pubectomy

More than 1/3 More chance of pubectomy

MM Koraitim, J Urol 2008, 179: 1879-81

ED due to Posterior Urethral Injuries Duplex Color Doppler

Instruments

Simple Lithotomy with Allen stirrups

Posterior urethral injury The goal of surgery

Tension free Bulbo-Membranous anastomosis

Elastic Lengthening

Crural Separation

Prostate apex and pubic bone

Approaches

Perineal 1. Bulbar urethral mobilization 2. Crural separation Elaborated perineal (Webster) 3. Inferior pubectomy 4. Supra-crural rerouting of urethra Perineo abdominal (Turner Warwick) 5. Total pubectomy 6. Omental wrap

Simple perineal repair 1.Bulbar urethra mobilized

Bulbar Urethra Transected Spatulated

Crural Separation 1

Deep Dorsal Vein : Retract on one side or Tie

Inferior Pubectomy 2

2 Anacılları procedures Crural Separation Inferior Pubectomy

Supra-Crural Rerouting 3

Anacıllar procedures

4.Supra-crural rerouting

Abdominal Approach

5.Posterior Pubectomy 6.Omental Wrap

Indian School of Urethral Surgery

www.strictureurethra.com