Sanjay Balwant Kulkarn i Center for Reconstructive Urology ... · Two stage! 1 - 2 cm Traumatic...
Transcript of Sanjay Balwant Kulkarn i Center for Reconstructive Urology ... · Two stage! 1 - 2 cm Traumatic...
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Management of urethral distraction injuries
Sanjay Balwant Kulkarni
Center for Reconstructive Urology Pune, India.
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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
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Open surgery
• Abdominal trauma- Laparotomy
• Bladder injury- Repair • Bladder neck injury- Repair • Rectal injury- Colostomy
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Urethral trauma
Emergency- Supra Pubic Catheter Stable patient- ? Endoscopic Realignment 3 months - Anastomotic urethroplasty
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Bulbar urethral strictureTraumatic!
< 2 cm! > 2 cm!
End-to-end ! Augmented !Anastomosis!
DVIU!Two stage!
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1 - 2 cm Traumatic bulbar urethral stricture
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Spatilation: Proximal-Perineal Distal-Dorsal
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Dorsal wall: Single layer Ventral wall: Two layer
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2 - 4 cm Traumatic bulbar urethral stricture
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Augmented anastomotic repair
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Injury -Posterior urethra plucked away Surgery -Bulbar urethra mobilized
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MCU+ RGU
Bladder Neck closed Bladder Neck opened
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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
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ED due to Posterior Urethral Injuries Duplex Color Doppler
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Instruments
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Simple Lithotomy with Allen stirrups
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Posterior urethral injury The goal of surgery
Tension free Bulbo-Membranous anastomosis
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Elastic Lengthening
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Crural Separation
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Prostate apex and pubic bone
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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
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Simple perineal repair 1.Bulbar urethra mobilized
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Bulbar Urethra Transected Spatulated
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Crural Separation 1
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Deep Dorsal Vein : Retract on one side or Tie
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Inferior Pubectomy 2
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2 Anacılları procedures Crural Separation Inferior Pubectomy
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Supra-Crural Rerouting 3
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Anacıllar procedures
4.Supra-crural rerouting
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Abdominal Approach
5.Posterior Pubectomy 6.Omental Wrap
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Indian School of Urethral Surgery
www.strictureurethra.com