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Complex strictures - Redo Urethroplasty

  1. Failed anastomotic urethroplasty for posterior urethral injuries.  The common cause for failure is inadequate excision of the scar at the apex of the prostatic urethra.  Unless, I see pink and mobile urethra with no white firm scar around the urethra, I do not perform the anastomosis.  Tension hematoma and ischaemia are other causes of failure.  A single attempt at DVIU is justified, it will be useful in those failed urethroplasties due to an anastomotic ring.  Longer defects need redo surgery.  I do get these failed urethroplasties and they are a big challenge.  I try to do anastomotic urethroplasty with extensive mobilization (avoiding penile urethral mobilization) and scar excision.  At times, I accept anastomosis under tension.  The other alternative of substitution urethroplasty with pedicled prepucial skin is not favored as a second choice.  It leads to permanent post micturition dribble due to diverticulam formation of the deep seated skin substation.
  2. Failed BMG urethroplasty – the success rate of dorsal onlay buccal mucosa graft urethroplasty is around 85% so 15% paitients have failed urethroplasty.  There are three reasons for failed urethroplasty.  1) proximal anastomotic ring  2) distal anastomotic ring  3) the whole BMG graft is lost. For anastomotic ring one attempt at DVIU is justified but if it fails a ventral onlay BMG urethroplasty give excellent results.

Complex strictures - Recto Urethral Fistula

Those patients who present with penetrating trauma to the rectum usually need immediate repair of the rectal tear wound and a covering colostomy.  Associated pelvic fracture urethral injury will need an open or trocar supra pubic cystostomy. Once the patient is stabilized he is discharged home and comes back three months later for step two i.e. anastomotic urethroplasty omental wrap. The approached used is the TW perineo abdominal progression approach. Through the perineal incision the bulbar urethra is dissected and transected inferior pubectomy is performed if required. The surgeon inserts his left index finger into the rectum and attempt is made to close the tear in the rectum. Many times, it is not possible to close this whole but if we perform a proper anastomotic urethroplasty and wrap omentum or the Gracilis muscle between the rectum and urethra the results are excellent. Once the patient is voiding well after catheter removal the colostomy is closed three months after the second step.

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