Urethroplasty

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Urethroplasty is the repair of injuries or defects in the urethral wall. Trauma, iatrogenic injury and infection are the most common causes of urethral/disability injuries that require improvement. Uretroplasty is considered a standard gold treatment for urethral stricture and offers better results in terms of recurrence rates than dilatation and urethrotomy. This may be the only useful treatment modality for long and complex strictures despite higher recurrence rates for this difficult treatment group. .

There are four common types of urethroplasty used; anastomotic, buccal oral mucosal onset, flap of scrotal or penile (graft), and Johansen urethroplasty.

With an average operating time of between three and eight hours, urethroplasty is not considered a minor surgery. Patients undergoing procedures with a shorter duration may have the comfort of returning home on the same day (between 20% and 30% of total urethroplasty patients). A hospital stay of two or three days is average. More complex procedures may require hospitalization of seven to ten days.

Video Urethroplasty

Fase operasi

These parts of operations are common to all specific operations.

Pre-operation

Ideally, the patient will undergo urethrography to visualize the position and length of the defect. Normal preoperative screening tests (as per the policies of the hospital treated, the anesthesiologist, and urologist) will be performed, and the patient will be advised not to swallow anything by mouth, "NPO", for a prescribed period of time (usually 8 to 12 hours) before the specified time.

Upon arrival in the area of ​​preoperative admission, the patient will be asked to wear a surgical gown and placed into the receiver bed, where monitoring vital signs, initiation of normal saline infusion, and pre-surgical medications including IV antibiotics, and benzodiazepine class sedatives , usually diazepam or midazolam will be started/given.

Operative

Patients will be transported to the operating room and procedures for the induction of the type of anesthesia selected by the patient and the medical staff will begin. Subject areas will be prepared by shaving, an antiseptic wash application (usually povidone iodine or chlorhexidine gluconate - if sensitive or allergic to the former), surgically removed and placed in the Lloyd-Davies position. Note: throughout the duration of the procedure, the patient's legs will be massaged and manipulated at prescribed intervals in an attempt to prevent compartment syndrome, complications from circulation and nerve compression resulting from lithotomy placement. Some hospitals use the Allen Medical Stirrup System, which automatically expands the compression sheath applied to the thighs of the stirrup device at predetermined intervals. This system is designed to prevent compartment syndrome in operations lasting more than six hours.

At this time the surgical team will conduct tests to determine whether anesthesia has been applied. After a satisfactory discovery, a suprapubic catheter (with a drainage system) will be inserted into the bladder (to create a urine transfer during the procedure), and the procedure chosen will then begin.

Note: The surgical procedures listed below may have minor variations in the methodology used from the surgeon to the surgeon. Consider the following as a common description of each procedure, although every precaution is taken to ensure the accuracy of the information.

Maps Urethroplasty

Operation type

Choice of procedure depends on several factors including:

• patient's physical condition
• the overall condition of the remaining urethra (not affected by stricture)
• the length of the defect (most determined by urethrography)
• some or aligned alignments
• the anatomical position of the defects associated with the prostate gland, urinary sphincter, and ejaculatory ducts
• position of the most patent area of ​​urethral wall (required for site onlay/graft location determination, most often dorsal or ventral)
• complications and scarring from previous surgery (ies), stent explanation (if present), and urethral wall condition
• availability of autograft network from buccal cavity (buccal mucosa) (main choice)
• availability of autograft networks of the penis and scrotum (secondary choice)
• skill level and training of surgeons performing procedure

Note: In more complex cases, more than one type of procedure can be performed, especially where there is a longer constriction.

Anastomotic urethroplasty

In this one-step procedure the urethra will be visualized (in the defective area), and the incision will begin at its midline (usually) using a bovie blade to dissect the dermal and sub-dermal layers to the muscles, corpus cavernosum, corpus spongiosum, and ventral urethral aspect exposed. Special care is used during dissection to prevent nerve and blood vessel damage (which can lead to erectile dysfunction or loss of touch penis sensation). The defect area is evaluated and marked both the lateral line, and on the distal and proximal (transverse) borders. Marked/labeled positioning sutures are secured (one, each) at the proximal and distal ends of the midline of the urethra closest to the cleavage points. Using the index finger, the urethra is gently separated from the cavernosum, and a specially designed retractor is then placed behind the urethra (to protect vulnerable areas from damage during transecting and removal of the urethral defect.Now the tip of the urethral patent is prepared using a technique called " spatulation ", which (essentially) allows for end-to-end anastomosis to adjust to the different diameters of the urethra.The silicone catheter is inserted through the penis and (temporary) distal-urethral tip, and threaded to the proximal-urethral end (temporal) leaving a wide loop for the surgeon to have access to the dorsal urethral aspect for micro suturing, and starting from anastomosis. The dorsal third dose of urethral anastomosis begins, completes, and the catheter is pulled slightly to allow its position in the urethra of pre-anastomosis. using microsurgical techniques, completed anastomosis and applied fibrin glue to the anastomotic seam line to help prevent leakage and fistula formation. The silicone guiding catheter will then be pulled from the penis and (a) replaced with a suitably sized Foley catheter (and urinary drainage system), and a closed incision (layer by layer). Some surgeons will inject local anesthesia such as 2% plain lidocaine or 0.5% bupivicaine into the area to allow patients additional periods of relief from discomfort.

Doppler microcirculation measurements of penile vascularization were performed at points of the way throughout the procedure, and the final assessment was taken and recorded. The incision is checked and applied, and the patient is returned to recovery.

(A) some surgeons prefer the use of suprapubic catheters, because they believe insertion of the urethral catheter inside can damage the anastomosis region

Average expected success rate: The success rate for this procedure is above 95%, anastomotic urethroplasty is considered the "gold standard" of surgical repair options. It is commonly used when the stricture is less than 2 cm, however, some surgeons have succeeded with defects approaching 3 cm.

Buccal mucosal onset disorder of the ventral urethra

In this one-step procedure the urethra will be visualized (in the defective area), and the incision will begin at its midline (usually) using a bovie blade to dissect the dermal and sub-dermal layers to the muscles, corpus cavernosum, corpus spongiosum, and ventral urethral aspect exposed. (a) Special care is used during dissection to prevent nerve and blood vessel damage (which can lead to erectile dysfunction or loss of touch penis sensation). The defect areas are evaluated and marked laterally mid-line, and (marked) the position of the stitches are positioned (one, each) at the proximal and distal ends of the urethra area closest to the border of the damaged area. At the same time, a urologist surgeon who is specially trained in buccal mucosal harvesting techniques will begin harvesting and repairing the inside of the patient's cheeks, according to the dimensions/shapes calculated and requested by the surgeon performing the urethral aspect of the procedure. If available, the maxillofacial or maxillofacial surgeon or ENT specialist will take the buccal mucosa according to the specification requested. Once taken, the buccal graft is given to the urethral surgeon, who will then prepare the graft by pruning and disposing of foreign tissue.

The surgeon will make the opening of the lateral incision between the known outer threshold of the defect, withdraw the opening of the incision to the desired diameter, and the position of the graft to cover the incision. This will form a tunnel, or diversion through a stricture that is 10 mm (optimal) in the approximate diameter, to allow the flow of urine. Using microsurgical techniques, buccal transplants will be sewn in place and fibrin glue is applied to the stitching line to prevent leakage and fistula formation. At this time the exact size of Foley catheter will be inserted through repair and into the bladder (and connected to the urinary drainage system), and the incision is closed (layer by layer). Some surgeons will inject local anesthesia such as 2% plain lidocaine or 0.5% bupivicaine into the area to allow patients additional periods of relief from discomfort.

Doppler microcirculation measurements of penile vascularization were performed at points of the way throughout the procedure, and the final assessment was taken and recorded. The incision is checked and applied, and the patient is returned to recovery.

(A) At this time, some surgeons prefer to include safety guidelines (such as those used in urethrotomy) of the urinary meatus, through stricture, and into the bladder for the purpose of maintaining the position.

(B) some surgeons prefer the use of suprapubic catheters, because they believe insertion of the urethral catheter inside can damage surgically repaired areas.

University of Kansas, Department of video Urology procedure

Average expected success rate: The success rate for this procedure is between 87 and 98%, urethroplasty onset of the piping mucosa is considered the best improvement option for strictures greater than 2 cm. In recent years, surgeons have applied the onlays to the dorsal aspect of the urethra with great success. The buccal mucosa is closest to the tissues that make up the urethra.

Flap island scrotal or penis (grafted) of the ventral urethra

In this one-step procedure the urethra will be visualized (in the defective area), and the incision will begin at its midline (usually) using a bovie blade to dissect the dermal and sub-dermal layers to the muscles, corpus cavernosum, corpus spongiosum, and ventral urethral aspect exposed. (a) Special care is used during dissection to prevent nerve and blood vessel damage (which can lead to erectile dysfunction or loss of touch penis sensation). The defect areas are evaluated and marked laterally mid-line, and (marked) the position of the stitches are positioned (one, each) at the proximal and distal ends of the urethra area closest to the border of the damaged area. The surgeon will harvest the tissue portion of the scrotum or foreskin of the penis (or what remains in circumcised men) in accordance with predetermined dimensions/shape. After taking, the graft is prepared to be installed by trimming and disposing of foreign tissue.

The surgeon will make the opening of the lateral incision between the known outer threshold of the defect, withdraw the opening of the incision to the desired diameter, and the position of the graft to cover the incision. This will form a tunnel, or diversion through a stricture that is 10 mm (optimal) in the approximate diameter, to allow the flow of urine. Using a microsurgical technique, a scrotum graft or a penis island crease will be sewn in place and glue fibrin applied to the stitching line to help prevent leakage and fistula formation. At this exact size (b) Foley catheter will be inserted through repair and into the bladder (and connected to the urinary drainage system), and the incision is closed (layer by layer). Some surgeons will inject local anesthesia such as 2% plain lidocaine or 0.5% bupivicaine into the area to allow patients additional periods of relief from discomfort.

Doppler microcirculation measurements of penile vascularization were performed at points of the way throughout the procedure, and the final assessment was taken and recorded. The incision is checked and applied, and the patient is returned to recovery.

(A) At this time, some surgeons prefer to include safety guidelines (such as those used in urethrotomy) of the urinary meatus, through stricture, and into the bladder for the purpose of maintaining the position.

(B) some surgeons prefer the use of suprapubic catheters, because they believe insertion of the urethral catheter inside can damage surgically repaired areas.

Average expected success rate: The success rate for this procedure is between 70% and 85%, pelvic thalplasti scrotum or island penis is considered the least attractive of the repair options for urethral defects; however, standard procedures used in the improvement of strictures greater than 4 cm. Like the onset of buccal mucosa, the surgeon has performed dorsal aspect procedures since the late 1990s, with an estimated success rate approaching 90%.

Uretroplasti Johansen

The Johansen procedure is sometimes referred to as "Johanson urethroplasty" is a two-stage procedure developed during the 1950s and 1960s by the Swedish surgeon Dr. Bengt Johansen, and was originally designed as surgical repair for hypospadias. Over the years, surgery has evolved into a fairly complex operation in which the damaged area of ​​the urethra is opened ventally and left open as buried skin strips with deep transfers made from scrotum or penile skin covering the repair area. A properly inserted body catheter is inserted, and the repaired area is temporarily closed (stitched in several locations, with packing and other underwear) until a completely new shift form is made, usually within six months. After the confirmation of the healing is complete, the catheter is withdrawn and the surgical site is permanently closed. There are many methods associated with the name "Johansen". The most severe urethral trauma is reconstructed using the Johansen urethroplastic procedure. This is also a procedure usually used in repair of damage caused by lichen sclerosus balinitis, also called BXO.

The Johansen procedure is used in the most difficult cases of traumatic reconstruction. Due to variations in practice in this procedure, estimates of success rates are not available.

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Post-procedural treatment

Constant monitoring of vital signs including pulse oximeter, cardiac monitoring (EKG), body temperature and blood pressure are performed by the anesthesiologist until the patient is discharged post-surgery to the post-surgical recovery unit. Once enough awake from the anesthetic agent has occurred, and if the patient is a candidate for the same day's debit, he (and the person responsible for his transport house) will be instructed in the care and discharge of the catheter and drainage system, cleansing the involved area (s) and method/interval for dressing change, monitoring of infection signs and for signs of catheter blockage. Patients will be prescribed for antibiotic or anti-infective drugs, urinary anti-spasmodic medications, and mild to moderate pain medications (estimated no more than a few days). Patients will be instructed to optimize bed rest during the first two days after surgery, restricted to absolutely no lifting, and instructed to consume high fiber diet and use stool softeners such as sodium docusate to help avoid straining during evacuation. After days 1 and 2, patients will be instructed to reasonably increase physical activity, and avoid becoming inactive. Adequate hydration is essential during the post-recovery phase of the procedure.

In accordance with the surgeon's preference, the retrograde uretrogram will be scheduled to coincide with the anticipated date of supercapubic or Foley catheter removal (usually 7 to 14 days postoperative, but some surgeons will attempt to remove in 3 to 5 days). In the post-10 day procedure, the stitching line will be evaluated, and the stitches removed if applicable (in most cases, the surgeon will use absorbable sutures, which require no removal).

The length of hospitalization is usually determined by:

• patient status/condition, post recovery
• after anesthesia/sedation/spinal anesthesia effects are used during the procedure
• anticipated post-surgical care, per treatment plan (change of change, change packing, and monitoring of surgical drainage - if used)
• monitoring of newly formed urethral cysostomy (Johansen urethroplasty) if applicable
• monitoring of a suprapubic catheter or Foley catheter for signs of infection and appropriate urine output if applicable
• palliative and anti-spasmodic drug titration (s) if applicable
• post a surgical complication if any

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Possible postoperative complications

Note: Uretroplasty is generally well tolerated with high success rates, serious complications occur in less than ten percent of patients although recurrent complications are particularly common in long and complex strictures.

• recurrence of stricture
• infection
• urinary incontinence (symptoms of incontinence often improve over time with strengthening exercises)
• urine retention requires intermittent catheterization to completely empty the bladder
• erectile dysfunction
• loss of penile sensation, decreased tactile sensation from penile shaft and corona
• retrograde ejaculation, ejaculation changes, and decreased orgasm intensity
• referenced pain
• urine fistula
• urinary urgency
• spraying urine
• hematoma
• external bleeding (from the stitching line)
• bleeding from the internal stitching line (looks like the discharge from the urethra)

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References

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External links

• Detroit Receives Hospital, Urology Reconstruction Center  ©
• Center for Urology Reconstruction at UC Irvine
• Support Group Stricture uretra
• Youtube (tm) video from uroskopi mukosa bukal bumal

Source of the article : Wikipedia