patients who are younger than 50 years old who are reasonable candidates for urethral reconstruction.
patients with short strictures of the bulbous urethra not associated with significant spongiofibrosis.
distraction injuries of the membranous urethrb. patients who have strictures associated with urethral fistul
children with bulbous urethral stricture disease.
Success requires total excision of the fibrosis with a widely spatulated anastomosis.
Reconstruction is facilitated by development of the intracrural space with infrapubectomy.
Excision and primary anastomosis reconstruction is severely limited and useful only for very proximal strictures 1 to 2â•¯cm in length.
In cases of longer strictures, excision with partial anastomosis allowing one wall to granulate offers acceptable results.
Performance of the excision and primary anastomosis technique is facilitated by dissection of the corpus spongiosum to the level of the glans penis.
Excision with strip anastomosis and onlay (augmented anastomosis) is an excellent form of reconstruction for strictures too long to be dealt with only by excision and primary anastomosis.
The use of the spongioplasty maneuver requires the total excision of all spongiofibrosis.
Vessel-sparing excision with primary anastomosis is not useful for distal bulbous urethral strictures.
The Barbagli operation combines the use of excision with staged augmented anastomosis.
The Monseur technique employed the use of mesh split-thickness skin.
They are of limited value in patients who have been previously circumcised.
Flap operations are best applied as individual techniques and require the surgeon to become intimately familiar with the individual steps of each technique.
The operation can conceptually become one operation with multidimensional application.
The operations are all based on mobilization of the extended Buck fascid. The operations require a comfortable understanding of the extended circumflex iliac superficial vascular pattern.
The circular skin islands, mechanically, are facilitated by dividing the dartos fascial flaps ventrally.
The “tubed flaps” in general are optimal for cases of short- to moderate-length strictures.
The scrotal skin island is a problematic flap and should be avoided at all cost.
The length of tubed segments can be limited by the aggressive mobilization of the corpus spongiosum.
Combined tissue transfer, the combination of graft patch and flap patch, has been shown to be superior to tubed reconstruction.
Because LS/BXO is a generalized skin condition, oral mucosa has been considered for reconstruction, with initial encouraging results.
Staged skin graft procedures have yielded excellent durable results.
The Urolume stent has proved to be an excellent option.
In most cases, because the lumen is severely stenotic, urethral resection with tubed flap reconstructive is preferable.
Patch flap techniques have provided excellent long-term success rates.
They are best managed with an aligning catheter placed to traction.
Inevitably are associated with injury to the pudendal nerves.
They are usually associated with full-thickness spongiofibrosis.
They can be partial, and this difference is easily defined by contrast studies.
Although they can involve any part of the membranous urethra, they most frequently occur at the juncture of the membranous urethra with the bulbous urethra.
optimally first evaluated with contrast studies.
always complicated by postoperative incontinence when contrast material is seen in the posterior urethre. never be evaluated with endoscopy in the acute-injury phase.
always defined with simultaneous cystogram and retrograde urethrogram.
often evaluated with an endoscope in the anterior urethra and a cystogram with the patient straining to void.
Continence is best predicted by the appearance of the bladder neck on endoscopy.
Continence is best addressed after a procedure to reestablish urethral continuity is performed.
Continence can be accurately predicted by contrast studies.
Location of the injury along the course of the membranous urethra is not associated with continence postoperatively.
Continence is best in patients with partial distraction injuries.
division of the attachment of the bulbospongiosum to the perineal body.
development of the intracavernosal (intracrural) space.
mobilization of the proximal corpus spongiosum.
dissection of the scarred Buck fascia from the corpus spongiosum.
Patients with reconstitution of an injured pudendal vessel, even if reconstitution was a unilateral phenomenon, are excellent candidates for posterior urethral reconstruction.
Long-segment failures are readily amenable to directvision internal urethrotomy with Urolume stent placement.
Patients with one intact pudendal artery are at risk for ischemic stenosis of the corpus spongiosum.
Most failures are due to technical anastomotic issues.
Inevitably, redo reconstruction requires a procedure using tissue transfer.
Division of the urethra/corpus spongiosum is virtually always indicated.
Correction of curvature is often achieved with mobilization of the corpus spongiosum alone.
It is usually present with either ventral curvature or ventral curvature associated with torsion.
It often can be corrected with maneuvers that lengthen the foreshortened ventral skin.
Is best straightened by an incision and grafting operation.
Correction is facilitated by tourniquet occlusion during artificial erections.
Curvature is usually dorsal.
In most cases, despite dissection and incision of tissues that appear inelastic, most patients require incision with grafting.
If length is an issue, the patient probably is more correctly characterized as having chordee without hypospadias.
It is optimally managed with incision and grafting to avoid foreshortening of the penis.
They are virtually never associated with “minimal” buckling traumd. Patients often have significant penile foreshortening.
Most are characterized by prominent dorsal scars.
There is usually an association with either hypospadias or epispadias.
In most cases, global cavernosal veno-occlusive dysfunction (CVOD) is not a complicating factor.
Physical properties of grafts are a function of the superficial dermal or laminar aree. Physical characteristics of flaps vary by the thickness of the underlying fat.
Only select tissues have inherent tissue tension.
They are a function of the collagen-elastin architecture because it is suspended in a mucopolysaccharide matrix.
Extensibility can be used synonymously with compliance.
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