Complex strictures - Redo Urethroplasty

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  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.