Terapia della Stenosi uretrale bulbare

Vi presentiamo alcune informazioni di massima utilità per capire la terapia giusta della stenosi uretrale bulbare.

 

Algoritmo per le stenosi dell’uretra bulbare

  • Stenosi corta ( < 1 cm), non obliterativa, “vergine”: Uretrotomia endoscopica (Successo 40-70%)
  • Stenosi obliterativa: uretroplastica anastomotica con o senza innesti (Successo >95%)
  • Stenosi non obliterativa corta (<2cm) o lunga (>2 cm) : uretroplastica di ampliamento dorsale o ventrale con innesti (Successo >90%)
  • Stenosi lunga, con piatto uretrale inutilizzabile: uretroplastica stadiata con o senza innesti (Successo 80%)

La letteratura riporta una percentuale di successo dell’Uretrotomia endoscopica sec. Sachse di circa il 70% nei restringimenti bulbari vergini, non-obliterativi e corti, rendendo plausibile un suo impiego in casi selezionati. Tuttavia recenti studi sui costi-benefici dell’uretroplastica comparati con le dilatazioni e l’uretrotomia hanno evidenziato che non c’è nessun vantaggio nel fare più di una uretrotomia prima di procedere ad un’uretroplastica; anzi in stenosi, vergini anche se significative, l’uretroplastica primaria rappresenta il trattamento migliore.

Fino ad oggi il gold standard per le stenosi bulbari corte (< 2 cm) obliterative o non-obliterative era la resezione ed anastomosi termino-terminale.

Quest’ultima è stata considerata la tecnica con la più alta percentuale di successo (> 95%) e che tende a perdurare nel tempo perché non impiega tessuti estranei all’uretra. L’opinione crescente dei chirurghi ricostruttivi dell’uretra, è che l’anastomosi termino-terminale causa un danno importante nella vascolarizzazione dell’uretra. Dagli studi effettuati risulta, infatti, che l’anastomosi termino-terminale può essere causa di complicanze sessuali (deficit erettile, alterazioni della sensibilità del glande, corda uretrale, curvatura del pene) : la nuova tendenza è quella di effettuare l’anastomosi termino-terminale solo nelle stenosi obliterative, mentre per le stenosi non-obliterative il gold standard è rappresentato dall’uretroplastica di ampliamento con un’innesto-toppa (il cosiddetto “patch-graft”), con una percentuale di successo >90%.

I risultati delle procedure ventrali e dorsali sono similari e la scelta dipenderà dalla familiarità del chirurgo con una piuttosto che con un’altra tecnica. Tuttavia, nel tratto bulbare prossimale l’ampliamento ventrale sembra tecnicamente più facile e meno aggressivo.

La facilità di prelievo e gli eccellenti risultati della MB hanno ridotto notevolmente l’impiego dei lembi peduncolati nella ricostruzioni bulbari.

Nelle stenosi bulbari prossimali a ridosso dell’uretra membranosa il trattamento chirurgico può causare un indebolimento del complesso sfinterico distale: il paziente deve quindi essere informato che un’eventuale futura chirurgia prostatica con compromissione dello sfintere prossimale residuo (collo vescicale) potrebbe essere causa di incontinenza.

Dilatazioni per stenosi dell’uretra bulbare è d’obbligo, al giorno d’oggi, abbandonare questa procedura che causa solo un peggioramento delle condizioni dell’uretra, lacerando il tessuto uretrale e determinando, nel tempo, un aumento della lunghezza della stenosi stessa. Le dilatazioni causano, inoltre, aumento delle infiammazioni ed infezioni urinarie. Le dilatazioni hanno dimostrato percentuale di successo della risoluzione della stenosi pari a 0%.


Uretrotomia endoscopica per stenosi dell’uretra bulbare:  deve essere effettuata esclusivamente per una stenosi primaria (mai trattate), corta (< 1 cm), dell’uretra bulbare. La prima uretrotomia ha percentuale di successo che varia da 40-70%. La seconda uretrotomia ha percentuale di successo pari a 0%, per cui le uretrotomie ripetute non vanno effettuate, anche perché causano un aumento della spongiofibrosi dell’uretra.


Posizionamento di stent uretrale per stenosi dell’uretra bulbare:  è d’obbligo, al giorno d’oggi, abbandonare questa procedura, che causa nel tempo (mesi o pochi anni) la distruzione completa del tessuto uretrale, trasformandolo in tessuto cicatriziale e determinando un aumento della stenosi. La rimozione dello stent risulta molto complessa e molte volte è necessario asportare l’uretra con lo stent in toto.


Chirurgia a cielo aperto per stenosi dell’uretra bulbare: l’uretroplastica è la soluzione per la stenosi dell’uretra bulbare: le varie tecniche chirurgiche hanno una percentuale di successo che varia da 80 a 95%.

 

 

Uretroplastica per stenosi dell’uretra bulbare distale

In questo articolo potete reperire tutte le informazioni relative all’uretroplastica per la stenosi dell’uretra bulbare distale:

 

FOTO BDUretroplastica per stenosi dell’uretra bulbare distale
FOTO V0FOTO V0
FOTO V01FOTO V01

 

Uretroplastica bulbare in tempo unico con innesto VENTRALE di mucosa buccale

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare distale senza la sezione del centro tendineo del perineo. Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto V1, V2]. Asportazione parziale di tessuto uretrale cicatriziale ed ampliamento del letto uretrale mediante innesto ventrale (sec. McAninch) di mucosa buccale  (prelevata dalla guancia destra o sinistra) [foto V3, V4, V5]. Spongioplastica mediante sutura continua [foto V6]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine). Medicazione compressiva.

FOTO V1FOTO V1
FOTO V2FOTO V2
FOTO V3FOTO V3
FOTO V4FOTO V4
FOTO V5FOTO V5
FOTO V6FOTO V6

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia  per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare  acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocistografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole. La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA: stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Quando si apre l’uretra, se il piatto uretrale dorsale non è molto compromesso, è possibile effettuare un innesto ventrale con graft di mucosa buccale. Può essere indicata  nei casi di  lichen sclerosus dell’uretra e dei genitali, nonchè nei casi di ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine.

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica aggiornata al 30/06/2015. Effettuate 768 uretroplastiche bulbari in tempo unico con mucosa buccale.  Percentuale di successo 91.2%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

 APPROFONDIMENTI:

Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. (Elliott SP, Metro MJ, McAninch JW.) J Urol. 2003 May;169(5):1754-7.    

PURPOSE:We investigate whether the short-term success rate (greater than 90%) of buccal mucosa free grafts in the bulbar urethra is sustained in the long term.  MATERIALS AND METHODS: In 60 patients a ventrally placed buccal mucosa graft was used for repair of bulbar urethral strictures. Of these patients 49 had undergone previous attempt at repair (urethroplasty in 4, internal urethrotomy in 45). Mean graft length was 4.8 cm. In 9 patients a distal penile fasciocutaneous flap was also used for repair of concomitant penile urethral stricture. In 8 of the 9 patients the buccal mucosa graft was combined with end-to-end urethroplasty and 2 buccal mucosa grafts were used in tandem in 1. Followup was at least 1 year in all cases (mean 47 months, range 12 to 107). Failure was defined as an obstructive voiding pattern with radiographic or cystoscopic evidence of recurrent stricture. RESULTS: Bulbar stricture repair was successful in 54 patients (90%) and 4 of the remaining 6 responded to 1 internal urethrotomy for a long-term success rate of 97%. Preoperative clinical characteristics were not significantly different between those who experienced success or failure. CONCLUSIONS: Long-term outcome analysis of ventrally placed buccal mucosa onlay grafts for bulbar urethral strictures demonstrates a durable success rate of 90%. This rate can be improved (97%) with the judicious use of internal urethrotomy.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.                                                                                                       

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 


Uretroplastica bulbare in tempo unico con innesto DORSALE di mucosa buccale

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare distale senza la  sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto A1, A2]. Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto A3, A4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale (sec. Asopa) con innesto  di mucosa buccale (prelevata dalla guancia destra o sinistra) [foto A5,A6]. Spongioplastica mediante sutura continua [foto A7]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).  Medicazione compressiva.

FOTO A1FOTO A1
FOTO A2FOTO A2
FOTO A3FOTO A3
FOTO A4FOTO A4
FOTO A5FOTO A5
FOTO A6FOTO A6
FOTO A7FOTO A7

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA:  terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia per 1 giorno. Dimisisoni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare  acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocistografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole. La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:  stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Quando si apre l’uretra, se il piatto uretrale è molto compromesso dorsalmente, viene parzialmente asportato e sostituito con la mucosa buccale. Può essere indicata  nei casi di  lichen sclerosus dell’uretra e dei genitali, nonchè nei casi di ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine.

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 4%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica aggiornata al 30/06/2015. Effettuate 75 uretroplastiche bulbari in tempo unico con mucosa buccale.  Percentuale di successo 89.4%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

APPROFONDIMENTI:

Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. (Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A.) Urology. 2001 Nov;58(5):657-9.

OBJECTIVES: To explore the feasibility of applying a dorsal free graft to treat urethral stricture by the ventral sagittal urethrotomy approach without mobilizing the urethra. METHODS: Twelve patients with long or multiple strictures of the anterior urethra were treated by a dorsal free full-thickness preputial or buccal mucosa graft. The urethra was not separated from the corporal bodies and was opened in the midline over the stricture. The floor of the urethra was incised, and an elliptical raw area was created over the tunica on which a free full-thickness graft of preputial or buccal mucosa was secured. The urethra was retubularized in one stage. RESULTS: After a follow-up of 8 to 40 months, one recurrence developed and required dilation. CONCLUSIONS: The ventral sagittal urethrotomy approach for dorsal free graft urethroplasty is not only feasible and successful, but is easy to perform.

 

Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. (Pisapati VL, Paturi S, Bethu S, Jada S, Chilumu R, Devraj R, Reddy B, Sriramoju V.) Eur Urol. 2009 Jul;56(1):201-5. Epub 2008 Jun 9.

BACKGROUND: Buccal mucosal graft (BMG) substitution urethroplasty has become popular in the management of intractable anterior urethral strictures with good results. Excellent long-term results have been reported by both dorsal and ventral onlay techniques. Asopa reported a successful technique for dorsal placement of BMG in long anterior urethral strictures through a ventral sagittal approach. OBJECTIVE: To evaluate prospectively the results and advantages of dorsal BMG urethroplasty for recurrent anterior urethral strictures by a ventral sagittal urethrotomy approach (Asopa technique). DESIGN, SETTING, AND PARTICIPANTS: From December 2002 to December 2007, a total of 58 men underwent dorsal BMG urethroplasty by a ventral sagittal urethrotomy approach for recurrent urethral strictures. Forty-five of these patients with a follow-up period of 12-60 mo were prospectively evaluated, and the results were analysed. INTERVENTION: The urethra was split twice at the site of the stricture both ventrally and dorsally without mobilising it from its bed, and the buccal mucosal graft was secured in the dorsal urethral defect. The urethra was then retubularised in one stage. RESULTS AND LIMITATIONS: The overall results were good (87%), with a mean follow-up period of 42 mo. Seven patients developed minor wound infection, and five patients developed fistulae. There were six recurrences (6:45, 13%) during the follow-up period of 12-60 mo. Two patients with a panurethral stricture and four with bulbar or penobulbar strictures developed recurrences and were managed by optical urethrotomy and self-dilatation. The medium-term results were as good as those reported with the dorsal urethrotomy approach. Long-term results from this and other series are awaited. More randomised trials and meta-analyses are needed to establish this technique as a procedure of choice in future. CONCLUSIONS: The ventral sagittal urethrotomy approach is easier to perform than the dorsal urethrotomy approach, has good results, and is especially useful in long anterior urethral strictures.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach  (Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A.) Urology. 2001 Nov;58(5):657-9.

OBJECTIVES: To explore the feasibility of applying a dorsal free graft to treat urethral stricture by the ventral sagittal urethrotomy approach without mobilizing the urethra. METHODS: Twelve patients with long or multiple strictures of the anterior urethra were treated by a dorsal free full-thickness preputial or buccal mucosa graft. The urethra was not separated from the corporal bodies and was opened in the midline over the stricture. The floor of the urethra was incised, and an elliptical raw area was created over the tunica on which a free full-thickness graft of preputial or buccal mucosa was secured. The urethra was retubularized in one stage. RESULTS: After a follow-up of 8 to 40 months, one recurrence developed and required dilation. CONCLUSIONS: The ventral sagittal urethrotomy approach for dorsal free graft urethroplasty is not only feasible and successful, but is easy to perform.

 

Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. (Pisapati VL, Paturi S, Bethu S, Jada S, Chilumu R, Devraj R, Reddy B, Sriramoju V.) Eur Urol. 2009 Jul;56(1):201-5. Epub 2008 Jun 9.

BACKGROUND: Buccal mucosal graft (BMG) substitution urethroplasty has become popular in the management of intractable anterior urethral strictures with good results. Excellent long-term results have been reported by both dorsal and ventral onlay techniques. Asopa reported a successful technique for dorsal placement of BMG in long anterior urethral strictures through a ventral sagittal approach. OBJECTIVE: To evaluate prospectively the results and advantages of dorsal BMG urethroplasty for recurrent anterior urethral strictures by a ventral sagittal urethrotomy approach (Asopa technique). DESIGN, SETTING, AND PARTICIPANTS: From December 2002 to December 2007, a total of 58 men underwent dorsal BMG urethroplasty by a ventral sagittal urethrotomy approach for recurrent urethral strictures. Forty-five of these patients with a follow-up period of 12-60 mo were prospectively evaluated, and the results were analysed. INTERVENTION: The urethra was split twice at the site of the stricture both ventrally and dorsally without mobilising it from its bed, and the buccal mucosal graft was secured in the dorsal urethral defect. The urethra was then retubularised in one stage. RESULTS AND LIMITATIONS: The overall results were good (87%), with a mean follow-up period of 42 mo. Seven patients developed minor wound infection, and five patients developed fistulae. There were six recurrences (6:45, 13%) during the follow-up period of 12-60 mo. Two patients with a panurethral stricture and four with bulbar or penobulbar strictures developed recurrences and were managed by optical urethrotomy and self-dilatation. The medium-term results were as good as those reported with the dorsal urethrotomy approach. Long-term results from this and other series are awaited. More randomised trials and meta-analyses are needed to establish this technique as a procedure of choice in future. CONCLUSIONS: The ventral sagittal urethrotomy approach is easier to perform than the dorsal urethrotomy approach, has good results, and is especially useful in long anterior urethral strictures.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

Uretroplastica bulbare in tempo unico con innesto DORSALE di prepuzio

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare distale senza la  sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto A1, A2]. Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto A3, A4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale (sec. Asopa) con innesto  di cute prepuziale (prelevata dalla faccia dorsale del pene o tramite semicirconcisione o circoncisione) [foto A11]. Spongioplastica mediante sutura continua. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).  Medicazione compressiva.

FOTO A1FOTO A1
FOTO A2FOTO A2
FOTO A3FOTO A3
FOTO A4FOTO A4
FOTO A11FOTO A11

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia  per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare  acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocistografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:Si può fare per una stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Quando si apre l’uretra, se il piatto uretrale è molto compromesso dorsalmente, viene parzialmente asportato e sostituito con il prepuzio.  Questa scelta del graft può essere fatta ogni qual volta il prepuzio sia sano e ben rappresentato. Può essere indicata  nei casi di  ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine. Sconsigliata, invece, nei casi di lichen sclerosus dell’uretra e dei genitali.

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 4%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica  aggiornata al 30/06/2015. Effettuate 37 uretroplastiche bulbari in tempo unico solo con innesto di prepuzio.  Percentuale di successo 91.2%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

APPROFONDIMENTI:

Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. (Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A.) Urology. 2001 Nov;58(5):657-9.

OBJECTIVES: To explore the feasibility of applying a dorsal free graft to treat urethral stricture by the ventral sagittal urethrotomy approach without mobilizing the urethra. METHODS: Twelve patients with long or multiple strictures of the anterior urethra were treated by a dorsal free full-thickness preputial or buccal mucosa graft. The urethra was not separated from the corporal bodies and was opened in the midline over the stricture. The floor of the urethra was incised, and an elliptical raw area was created over the tunica on which a free full-thickness graft of preputial or buccal mucosa was secured. The urethra was retubularized in one stage. RESULTS: After a follow-up of 8 to 40 months, one recurrence developed and required dilation. CONCLUSIONS: The ventral sagittal urethrotomy approach for dorsal free graft urethroplasty is not only feasible and successful, but is easy to perform.

 

Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. (Pisapati VL, Paturi S, Bethu S, Jada S, Chilumu R, Devraj R, Reddy B, Sriramoju V.) Eur Urol. 2009 Jul;56(1):201-5. Epub 2008 Jun 9.

BACKGROUND: Buccal mucosal graft (BMG) substitution urethroplasty has become popular in the management of intractable anterior urethral strictures with good results. Excellent long-term results have been reported by both dorsal and ventral onlay techniques. Asopa reported a successful technique for dorsal placement of BMG in long anterior urethral strictures through a ventral sagittal approach. OBJECTIVE: To evaluate prospectively the results and advantages of dorsal BMG urethroplasty for recurrent anterior urethral strictures by a ventral sagittal urethrotomy approach (Asopa technique). DESIGN, SETTING, AND PARTICIPANTS: From December 2002 to December 2007, a total of 58 men underwent dorsal BMG urethroplasty by a ventral sagittal urethrotomy approach for recurrent urethral strictures. Forty-five of these patients with a follow-up period of 12-60 mo were prospectively evaluated, and the results were analysed. INTERVENTION: The urethra was split twice at the site of the stricture both ventrally and dorsally without mobilising it from its bed, and the buccal mucosal graft was secured in the dorsal urethral defect. The urethra was then retubularised in one stage. RESULTS AND LIMITATIONS: The overall results were good (87%), with a mean follow-up period of 42 mo. Seven patients developed minor wound infection, and five patients developed fistulae. There were six recurrences (6:45, 13%) during the follow-up period of 12-60 mo. Two patients with a panurethral stricture and four with bulbar or penobulbar strictures developed recurrences and were managed by optical urethrotomy and self-dilatation. The medium-term results were as good as those reported with the dorsal urethrotomy approach. Long-term results from this and other series are awaited. More randomised trials and meta-analyses are needed to establish this technique as a procedure of choice in future. CONCLUSIONS: The ventral sagittal urethrotomy approach is easier to perform than the dorsal urethrotomy approach, has good results, and is especially useful in long anterior urethral strictures.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

 

Uretroplastica bulbare in tempo unico con innesto DORSALE + VENTRALE di mucosa buccale  

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare distale senza la  sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto DV1,DV2].  Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto DV3, DV4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale ed ampliamento ventrale (sec. Palminteri),  con innesto di mucosa buccale [foto DV5, DV6, DV7, DV9]. Il prelievo di mucosa buccale può essere unico e diviso in due parti [foto DV8] oppure, se non è sufficiente, può essere  effettuato un prelievo da entrambe le guance. Spongioplastica mediante sutura continua [foto DV10]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine). Medicazione compressiva.

FOTO DV1FOTO DV1
FOTO DV2FOTO DV2
FOTO DV3FOTO DV3
FOTO DV4FOTO DV4
FOTO DV5FOTO DV5
FOTO DV6FOTO DV6
FOTO DV7FOTO DV7
FOTO DV8FOTO DV8
FOTO DV9FOTO DV9
FOTO DV10FOTO DV10

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocistografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole. La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Questo tipo di uretroplastica è utile nelle stenosi molto serrate, in cui un solo apliamento dorsale o ventrale, non sarebbe sufficiente a creare un’uretra di calibro adeguato. Può essere indicata  nei casi di  lichen sclerosus dell’uretra e dei genitali, nonchè nei casi di ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine.

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica aggiornata al 30/06/2015. Effettuate 197 uretroplastiche bulbari in tempo unico con mucosa buccale.  Percentuale di successo 92.4%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

APPROFONDIMENTI

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. (Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, Molon A.) Eur Urol. 2008 Jan;53(1):81-9. Epub 2007 Jun 

OBJECTIVES: We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG). METHODS: From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation. RESULTS: Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy. CONCLUSIONS: Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.

 

Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. (Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A.) J Urol. 2011 May;185(5):1766-71. Epub 2011 Mar 21.

PURPOSE: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. MATERIALS AND METHODS: Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. RESULTS: Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life. CONCLUSIONS: In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

 

Uretroplastica bulbare in tempo unico con innesto DORSALE + VENTRALE di mucosa buccale e prepuzio

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare distale senza la  sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto DV1, DV15].  Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto DV4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale    ed ampliamento ventrale (sec. Palminteri),  con innesto dorsdale di cute prepuziale (prelevata dalla faccia dorsale del pene) [foto 16 ] ed innesto ventrale di mucosa buccale [foto DV17, DV18, DV19 ]. Spongioplastica mediante sutura continua [foto DV10]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia dove è stato fatto il prelievo di mucosa buccale per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocistografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole. La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:Si può fare per una stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Questo tipo di uretroplastica è utile nelle stenosi molto serrate, in cui un sono apliamento dorsale o ventrale, non sarebbe sufficiente a creare un’uretra di calibro adeguato. Se non è sufficiente un prelievo di mucosa buccale, per effettuare un ampiamento adeguato del lume uretrale,  si può utilizzare un innesto dorsale di prepuzio ed un innesto ventrale di mucosa buccale.  Può essere indicata  nei casi di  ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine. Sconsigliata, invece, nei casi di lichen sclerosus dell’uretra e dei genitali.

COMPLICANZE: sanguinamento<1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica  aggiornata al 30/06/2015. Effettuate 35 uretroplastiche bulbari in tempo unico con prepuzio e/o mucosa buccale.  Percentuale di successo 94.6%.

CENTRO URETRA IN ITALIA: è possibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

APPROFONDIMENTI

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. (Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, Molon A.) Eur Urol. 2008 Jan;53(1):81-9. Epub 2007 Jun 8

OBJECTIVES: We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG). METHODS: From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation. RESULTS: Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy. CONCLUSIONS: Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.

 

Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. (Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A.) J Urol. 2011 May;185(5):1766-71. Epub 2011 Mar 21.

PURPOSE: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. MATERIALS AND METHODS: Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. RESULTS: Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life. CONCLUSIONS: In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

Uretroplastica bulbare in tempo unico con innesto DORSALE + VENTRALE di mucosa buccale e prepuzio

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare distale senza la  sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto DV1,DV15].  Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto DV4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale    ed ampliamento ventrale (sec. Palminteri),  con innesto dorsdale di cute prepuziale (prelevata dalla faccia dorsale del pene) [foto 16 ] ed innesto ventrale di mucosa buccale [foto DV17, DV18, DV19 ]. Spongioplastica mediante sutura continua [foto DV10]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

FOTO DV1FOTO DV1
FOTO DV15FOTO DV15
FOTO DV4FOTO DV4
FOTO DV17FOTO DV17
FOTO DV18FOTO DV18
FOTO DV19FOTO DV19
FOTO DV10FOTO DV10

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA:  terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia dove è stato fatto il prelievo di mucosa buccale per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocistografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole. La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:Si può fare per una stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Questo tipo di uretroplastica è utile nelle stenosi molto serrate, in cui un sono apliamento dorsale o ventrale, non sarebbe sufficiente a creare un’uretra di calibro adeguato. Se non è sufficiente un prelievo di mucosa buccale, per effettuare un ampiamento adeguato del lume uretrale,  si può utilizzare un innesto dorsale di prepuzio ed un innesto ventrale di mucosa buccale. Può essere indicata  nei casi di  ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine. Sconsigliata, invece, nei casi di lichen sclerosus dell’uretra e dei genitali

COMPLICANZE: sanguinamento<1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica  aggiornata al 30/06/2015. Effettuate 35 uretroplastiche bulbari in tempo unico con prepuzio e/o mucosa buccale.  Percentuale di successo 94.6%.

CENTRO URETRA IN ITALIA: è possibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

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Uretroplastica per stenosi dell’uretra bulbare prossimale

In questo articolo potete reperire tutte le informazioni relative all’uretroplastica per la stenosi dell’uretra bulbare prossimale:

Uretroplastica per stenosi dell'uretra bulbare prossimale Uretroplastica pe stenosi dell’uretra bulbare prossimale
FOTO V9FOTO V9
FOTO V8FOTO V8

 

 

Uretroplastica bulbare in tempo unico con innesto VENTRALE di mucosa buccale

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare prossimale evitando, se possibile, la sezione del centro tendineo del perineo. Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto V1, V2]. Asportazione parziale di tessuto uretrale cicatriziale ed ampliamento del letto uretrale mediante innesto ventrale (sec. McAninch) di mucosa buccale  (prelevata dalla guancia destra o sinistra) [foto V3, V4, V5]. Spongioplastica mediante sutura continua [foto V6]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

FOTO V1FOTO V1
FOTO V2FOTO V2
FOTO V3FOTO V3
FOTO V4FOTO V4
FOTO V5FOTO V5
FOTO V6FOTO V6

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia  per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare  acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocisografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole.  La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:  stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Quando si apre l’uretra, se il piatto uretrale dorsale risulta utilizzabile, è possibile effettuare un innesto ventrale con graft di mucosa buccale. Può essere indicata  nei casi di  lichen sclerosus dell’uretra e dei genitali, nonchè nei casi di ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica aggiornata al 30/06/2015. Effettuate 768 uretroplastiche bulbari in tempo unico con mucosa buccale.  Percentuale di successo 91.2%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

 

APPROFONDIMENTI:

Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction.(Elliott SP, Metro MJ, McAninch JW.) J Urol. 2003 May;169(5):1754-7.

PURPOSE: We investigate whether the short-term success rate (greater than 90%) of buccal mucosa free grafts in the bulbar urethra is sustained in the long term. MATERIALS AND METHODS: In 60 patients a ventrally placed buccal mucosa graft was used for repair of bulbar urethral strictures. Of these patients 49 had undergone previous attempt at repair (urethroplasty in 4, internal urethrotomy in 45). Mean graft length was 4.8 cm. In 9 patients a distal penile fasciocutaneous flap was also used for repair of concomitant penile urethral stricture. In 8 of the 9 patients the buccal mucosa graft was combined with end-to-end urethroplasty and 2 buccal mucosa grafts were used in tandem in 1. Followup was at least 1 year in all cases (mean 47 months, range 12 to 107). Failure was defined as an obstructive voiding pattern with radiographic or cystoscopic evidence of recurrent stricture. RESULTS: Bulbar stricture repair was successful in 54 patients (90%) and 4 of the remaining 6 responded to 1 internal urethrotomy for a long-term success rate of 97%. Preoperative clinical characteristics were not significantly different between those who experienced success or failure. CONCLUSIONS: Long-term outcome analysis of ventrally placed buccal mucosa onlay grafts for bulbar urethral strictures demonstrates a durable success rate of 90%. This rate can be improved (97%) with the judicious use of internal urethrotomy.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures.(Mangera A, Patterson JM, Chapple CR.)Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

 


Uretroplastica bulbare in tempo unico con innesto DORSALE di mucosa buccale

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare prossimale evitando, se possibile, la sezione del centro tendineo del perineo. Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto A1, A2]. Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto A3, A4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale (sec. Asopa) con innesto  di mucosa buccale (prelevata dalla guancia destra o sinistra) [foto A5, A6]. Spongioplastica mediante sutura continua [foto A7]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

FOTO A1FOTO A1
FOTO A2FOTO A2
FOTO A3FOTO A3
FOTO A4FOTO A4
FOTO A5FOTO A5
FOTO A6FOTO A6
FOTO A7FOTO A7

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA:  terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia per 1 giorno. Dimisisoni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare  acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocisografia minzionale di controllo, a 21 giorni dall’intervento chirurgico, per verificare se ci sono fistole. La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:  stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Quando si apre l’uretra, se il piatto uretrale è molto compromesso dorsalmente, viene parzialmente asportato e sostituito con la mucosa buccale. Può essere indicata  nei casi di  lichen sclerosus dell’uretra e dei genitali, nonchè nei casi di ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 4%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica aggiornata al 30/06/2015. Effettuate 75 uretroplastiche bulbari in tempo unico con mucosa buccale.  Percentuale di successo 89.4%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

 

APPROFONDIMENTI:

Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach.(Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A.) Urology. 2001 Nov;58(5):657-9.

OBJECTIVES: To explore the feasibility of applying a dorsal free graft to treat urethral stricture by the ventral sagittal urethrotomy approach without mobilizing the urethra. METHODS: Twelve patients with long or multiple strictures of the anterior urethra were treated by a dorsal free full-thickness preputial or buccal mucosa graft. The urethra was not separated from the corporal bodies and was opened in the midline over the stricture. The floor of the urethra was incised, and an elliptical raw area was created over the tunica on which a free full-thickness graft of preputial or buccal mucosa was secured. The urethra was retubularized in one stage. RESULTS: After a follow-up of 8 to 40 months, one recurrence developed and required dilation. CONCLUSIONS: The ventral sagittal urethrotomy approach for dorsal free graft urethroplasty is not only feasible and successful, but is easy to perform.

 

Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. (Pisapati VL, Paturi S, Bethu S, Jada S, Chilumu R, Devraj R, Reddy B, Sriramoju V.) Eur Urol. 2009 Jul;56(1):201-5. Epub 2008 Jun 9.

BACKGROUND: Buccal mucosal graft (BMG) substitution urethroplasty has become popular in the management of intractable anterior urethral strictures with good results. Excellent long-term results have been reported by both dorsal and ventral onlay techniques. Asopa reported a successful technique for dorsal placement of BMG in long anterior urethral strictures through a ventral sagittal approach. OBJECTIVE: To evaluate prospectively the results and advantages of dorsal BMG urethroplasty for recurrent anterior urethral strictures by a ventral sagittal urethrotomy approach (Asopa technique). DESIGN, SETTING, AND PARTICIPANTS: From December 2002 to December 2007, a total of 58 men underwent dorsal BMG urethroplasty by a ventral sagittal urethrotomy approach for recurrent urethral strictures. Forty-five of these patients with a follow-up period of 12-60 mo were prospectively evaluated, and the results were analysed. INTERVENTION: The urethra was split twice at the site of the stricture both ventrally and dorsally without mobilising it from its bed, and the buccal mucosal graft was secured in the dorsal urethral defect. The urethra was then retubularised in one stage. RESULTS AND LIMITATIONS: The overall results were good (87%), with a mean follow-up period of 42 mo. Seven patients developed minor wound infection, and five patients developed fistulae. There were six recurrences (6:45, 13%) during the follow-up period of 12-60 mo. Two patients with a panurethral stricture and four with bulbar or penobulbar strictures developed recurrences and were managed by optical urethrotomy and self-dilatation. The medium-term results were as good as those reported with the dorsal urethrotomy approach. Long-term results from this and other series are awaited. More randomised trials and meta-analyses are needed to establish this technique as a procedure of choice in future. CONCLUSIONS: The ventral sagittal urethrotomy approach is easier to perform than the dorsal urethrotomy approach, has good results, and is especially useful in long anterior urethral strictures.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT:  Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

Uretroplastica bulbare in tempo unico con innesto DORSALE di prepuzio

TECNICA: Incisione perineale ad Y rovesciata. Isolamento dell’uretra bulbare prossimale. Se possibile evitare la sezione del centro tendineo del perineo. Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto A1, A2]. Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto A3, A4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale (sec. Asopa) con innesto  di cute prepuziale (prelevata dalla faccia dorsale del pene o tramite semicirconcisione o circoncisione) [foto A10, A11]. Spongioplastica mediante sutura continua. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

FOTO A1FOTO A1
FOTO A2FOTO A2
FOTO A3FOTO A3
FOTO A4FOTO A4
FOTO A11FOTO A11
FOTO A7FOTO A7

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 3 giorni con ghiaccio sul perineo. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: Disinfezione della ferita con Betadine soluzione. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare betadine o soluzione fisiologica per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocisografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,  per verificare se ci sono fistole.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:Si può fare per una stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Se il piatto uretrale risulta mediamente compromesso.  Può essere indicata  nei casi di  ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine. Sconsigliata, invece, nei casi di lichen sclerosus dell’uretra e dei genitali

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 4%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica  aggiornata al 30/06/2015. Effettuate 37 uretroplastiche bulbari in tempo unico solo con innesto di prepuzio.  Percentuale di successo 91.2%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

 

APPROFONDIMENTI:

Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. (Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A.) Urology. 2001 Nov;58(5):657-9.

OBJECTIVES: To explore the feasibility of applying a dorsal free graft to treat urethral stricture by the ventral sagittal urethrotomy approach without mobilizing the urethra. METHODS: Twelve patients with long or multiple strictures of the anterior urethra were treated by a dorsal free full-thickness preputial or buccal mucosa graft. The urethra was not separated from the corporal bodies and was opened in the midline over the stricture. The floor of the urethra was incised, and an elliptical raw area was created over the tunica on which a free full-thickness graft of preputial or buccal mucosa was secured. The urethra was retubularized in one stage. RESULTS: After a follow-up of 8 to 40 months, one recurrence developed and required dilation. CONCLUSIONS: The ventral sagittal urethrotomy approach for dorsal free graft urethroplasty is not only feasible and successful, but is easy to perform.


Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique.(Pisapati VL, Paturi S, Bethu S, Jada S, Chilumu R, Devraj R, Reddy B, Sriramoju V.) Eur Urol. 2009 Jul;56(1):201-5. Epub 2008 Jun 9.

 BACKGROUND: Buccal mucosal graft (BMG) substitution urethroplasty has become popular in the management of intractable anterior urethral strictures with good results. Excellent long-term results have been reported by both dorsal and ventral onlay techniques. Asopa reported a successful technique for dorsal placement of BMG in long anterior urethral strictures through a ventral sagittal approach. OBJECTIVE: To evaluate prospectively the results and advantages of dorsal BMG urethroplasty for recurrent anterior urethral strictures by a ventral sagittal urethrotomy approach (Asopa technique). DESIGN, SETTING, AND PARTICIPANTS: From December 2002 to December 2007, a total of 58 men underwent dorsal BMG urethroplasty by a ventral sagittal urethrotomy approach for recurrent urethral strictures. Forty-five of these patients with a follow-up period of 12-60 mo were prospectively evaluated, and the results were analysed. INTERVENTION: The urethra was split twice at the site of the stricture both ventrally and dorsally without mobilising it from its bed, and the buccal mucosal graft was secured in the dorsal urethral defect. The urethra was then retubularised in one stage. RESULTS AND LIMITATIONS: The overall results were good (87%), with a mean follow-up period of 42 mo. Seven patients developed minor wound infection, and five patients developed fistulae. There were six recurrences (6:45, 13%) during the follow-up period of 12-60 mo. Two patients with a panurethral stricture and four with bulbar or penobulbar strictures developed recurrences and were managed by optical urethrotomy and self-dilatation. The medium-term results were as good as those reported with the dorsal urethrotomy approach. Long-term results from this and other series are awaited. More randomised trials and meta-analyses are needed to establish this technique as a procedure of choice in future. CONCLUSIONS: The ventral sagittal urethrotomy approach is easier to perform than the dorsal urethrotomy approach, has good results, and is especially useful in long anterior urethral strictures.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures.(Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

 

Uretroplastica bulbare in tempo unico con innesto DORSALE + VENTRALE di mucosa buccale

TECNICA: Incisione perineale mediana. Isolamento dell’uretra bulbare prossimale evitando, se possibile, la sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto DV1, DV2].  Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto DV3, DV4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale ed ampliamento ventrale (sec. Palminteri),  con innesto di mucosa buccale [foto DV5, DV6, DV7, DV9]. Il prelievo di mucosa buccale può essere unico e diviso in due parti [foto DV8] oppure, se non è sufficiente, può essere  effettuato un prelievo da entrambe le guance. Spongioplastica mediante sutura continua [foto DV10]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

FOTO DV1FOTO DV1
FOTO DV2FOTO DV2
FOTO DV4FOTO DV4
FOTO DV3FOTO DV3
FOTO DV5FOTO DV5
FOTO DV6FOTO DV6
FOTO DV7FOTO DV7
FOTO DV8FOTO DV8
FOTO DV9FOTO DV9
FOTO DV10FOTO DV10

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia  per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare  acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocisografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole.  La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA: stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Questo tipo di uretroplastica è utile nelle stenosi molto serrate, in cui un sono apliamento dorsale o ventrale, non sarebbe sufficiente a creare un’uretra di calibro adeguato. Può essere indicata  nei casi di  lichen sclerosus dell’uretra e dei genitali, nonchè nei casi di ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica aggiornata al 30/06/2015. Effettuate 197 uretroplastiche bulbari in tempo unico con mucosa buccale.  Percentuale di successo 92.4%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

 

 APPROFONDIMENTI

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, Molon A. Eur Urol. 2008 Jan;53(1):81-9. Epub 2007 Jun 8

OBJECTIVES: We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG). METHODS: From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation.

RESULTS: Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy. CONCLUSIONS: Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.

 

Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A.) J Urol. 2011 May;185(5):1766-71. Epub 2011 Mar 21.

PURPOSE: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. MATERIALS AND METHODS: Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. RESULTS: Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life.

CONCLUSIONS: In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures.(Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

Uretroplastica bulbare in tempo unico con innesto DORSALE + VENTRALE di mucosa buccale e prepuzio

TECNICA:  Incisione perineale mediana. Isolamento dell’uretra bulbare prossimale evitando, se possibile, la sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto DV1, DV15].  Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto DV4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale    ed ampliamento ventrale (sec. Palminteri),  con innesto dorsdale di cute prepuziale (prelevata dalla faccia dorsale del pene) [foto 16 ] ed innesto ventrale di mucosa buccale [foto DV17, DV18, DV19]. Spongioplastica mediante sutura continua [foto DV10]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

FOTO DV1FOTO DV1
FOTO DV15FOTO DV15
FOTO DV4FOTO DV4
FOTO DV17FOTO DV17
FOTO DV18FOTO DV18
FOTO DV19FOTO DV19
FOTO DV10FOTO DV10

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia dove è stato fatto il prelievo di mucosa buccale per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocisografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole.  La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:Si può fare per una stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Questo tipo di uretroplastica è utile nelle stenosi molto serrate, in cui un sono apliamento dorsale o ventrale, non sarebbe sufficiente a creare un’uretra di calibro adeguato. Se non è sufficiente un prelievo di mucosa buccale, per effettuare un ampiamento adeguato del lume uretrale,  si può utilizzare un innesto dorsale di prepuzio ed un innesto ventrale di mucosa buccale. Può essere indicata  nei casi di  ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine. Sconsigliata, invece, nei casi di lichen sclerosus dell’uretra e dei genitali

COMPLICANZE: sanguinamento<1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica  aggiornata al 30/06/2015. Effettuate 35 uretroplastiche bulbari in tempo unico con prepuzio e/o mucosa buccale.  Percentuale di successo 94.6%.

CENTRO URETRA IN ITALIA: è possibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

 

APPROFONDIMENTI:

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. (Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, Molon A.) Eur Urol. 2008 Jan;53(1):81-9. Epub 2007 Jun 

OBJECTIVES: We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG). METHODS: From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation. RESULTS: Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy. CONCLUSIONS: Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.

 

Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A.) J Urol. 2011 May;185(5):1766-71. Epub 2011 Mar 21.

PURPOSE: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. MATERIALS AND METHODS: Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. RESULTS: Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life.

CONCLUSIONS: In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Mangera A, Patterson JM, Chapple CR.  Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 


Uretroplastica per stenosi lunga dell’uretra bulbare

In questo articolo potete reperire tutte le informazioni relative all’uretroplastica per la stenosi stenosi lunga dell’uretra bulbare :

FOTO BLUretroplastica per stenosi lunga dell’uretra bulbare

 

 

 

Uretroplastica bulbare in tempo unico con innesto DORSALE + VENTRALE di mucosa buccale e prepuzio

TECNICA:  Incisione perineale mediana. Isolamento dell’uretra bulbare evitando, se possibile, la sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico [foto DV1,DV15].  Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa [foto DV4]. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale  ed ampliamento ventrale (sec. Palminteri),  con innesto dorsale di cute prepuziale (prelevata dalla faccia dorsale del pene) [foto 16 ] ed innesto ventrale di mucosa buccale [foto DV17, DV18, DV19 ]. Spongioplastica mediante sutura continua [foto DV10]. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

FOTO DV1FOTO DV1
FOTO DV15FOTO DV15
FOTO DV4FOTO DV4
FOTO DV17FOTO DV17
FOTO DV18FOTO DV18
FOTO DV19FOTO DV19
FOTO DV10FOTO DV10

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio  sulla guancia dove è stato fatto il prelievo di mucosa buccale per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocistografia minzionale di controllo, a 21 giorni dall’intervento chirurgico, per verificare se ci sono fistole. La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:Si può fare per una stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Questo tipo di uretroplastica è utile nelle stenosi molto serrate, in cui un sono apliamento dorsale o ventrale, non sarebbe sufficiente a creare un’uretra di calibro adeguato. Se non è sufficiente un prelievo di mucosa buccale, per effettuare un ampiamento adeguato del lume uretrale,  si può utilizzare un innesto dorsale di prepuzio ed un innesto ventrale di mucosa buccale. Può essere indicata  nei casi di  ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine. Sconsigliata, invece, nei casi di lichen sclerosus dell’uretra e dei genitali

COMPLICANZE: sanguinamento<1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica  aggiornata al 30/06/2015. Effettuate 35 uretroplastiche bulbari in tempo unico con prepuzio e/o mucosa buccale.  Percentuale di successo 94.6%.

CENTRO URETRA IN ITALIA: è possibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

 

 

APPROFONDIMENTI

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction.(Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, Molon A.) Eur Urol. 2008 Jan;53(1):81-9. Epub 2007 Jun 8

OBJECTIVES: We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG).  METHODS: From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation.  RESULTS: Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy.CONCLUSIONS: Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.

Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. (Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A.) J Urol. 2011 May;185(5):1766-71. Epub 2011 Mar 21.

PURPOSE: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. MATERIALS AND METHODS: Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. RESULTS: Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life. CONCLUSIONS: In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

 

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 


Uretroplastica bulbare in tempo unico con innesto DORSALE + VENTRALE  di mucosa buccale

TECNICA (guarda il video B2): Incisione perineale mediana. Isolamento dell’uretra bulbare prossimale evitando, se possibile, la sezione del centro tendineo del perineo.  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico.  Incisione mediana del piatto uretrale stenotico e lateralizzazione delle due bande di spongiosa. Asportazione parziale del tessuto cicatriziale uretrale a livello della stenosi. Si confeziona uretroplastica di ampliamento dorsale ed ampliamento ventrale sec. Palminteri,  con innesto di mucosa buccale. Il prelievo di mucosa buccale può essere unico e diviso in due parti oppure, se non è sufficiente, può essere  effettuato un prelievo da entrambe le guance. Spongioplastica mediante sutura continua. Drenaggio. Parete a strati. Si consiglia Catetere Foley 18 Fr (siliconato e scanalato) per 21 giorni (sempre collegato al sacchetto della raccolta urine).

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA:  Chinolonici per 5 giorni poi a seguire Monuril 1 bustina ogni 5 giorni, fino alla rimozione del catetere.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 2 giorni con ghiaccio sul perineo. Ghiaccio sulla guancia per 1 giorno. Dimissioni in 3° giornata postoperatoria.

MEDICAZIONI: La ferita perineale può essere pulita con acqua. Tra catetere e meato escono delle secrezioni-incrostazioni che vanno pulite più volte al giorno. Si consiglia di utilizzare  acqua o soluzione fisiologica su una garza per pulire il  catetere.

URETROCISTOGRAFIA MINZIONALE: Importante effettuare l’uretrocistografia minzionale di controllo, a 21 giorni dall’intervento chirurgico,per verificare se ci sono fistole. La percentuale di fistola uretrale insorta dopo uretroplastica bulbare, effettuate nel nostro Centro, è il 5%. Tutte le fistole uretrali sono state risolte mediante il posizionamento di catetere uretrale per ulteriori 10 o 15 o 20 giorni, a seconda dell’entità della fistola.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:stenosi bulbare corta (< 2cm) o lunga (> 2cm), ma solo  se  la stenosi non è obliterativa. Questo tipo di uretroplastica è utile nelle stenosi molto serrate, in cui un sono apliamento dorsale o ventrale, non sarebbe sufficiente a creare un’uretra di calibro adeguato. Può essere indicata  nei casi di  lichen sclerosus dell’uretra e dei genitali, nonchè nei casi di ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine

COMPLICANZE: sanguinamento <1%, infezione <2%. Fistola 3%

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica aggiornata al 30/06/2015. Effettuate 197 uretroplastiche bulbari in tempo unico con mucosa buccale.  Percentuale di successo 92.4%.

CENTRO URETRA IN ITALIA: è possibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

 

APPROFONDIMENTI:

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. (Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, Molon A.) Eur Urol. 2008 Jan;53(1):81-9. Epub 2007 Jun 8

OBJECTIVES: We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG). METHODS: From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation.

RESULTS: Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy. CONCLUSIONS: Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.

 

Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. (Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A.) J Urol. 2011 May;185(5):1766-71. Epub 2011 Mar 21.

PURPOSE: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. MATERIALS AND METHODS: Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. RESULTS: Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life. CONCLUSIONS: In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. (Mangera A, Patterson JM, Chapple CR.) Eur Urol. 2011 May;59(5):797-814. Epub 2011 Feb 24. Review.

CONTEXT: Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended. OBJECTIVE: Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery. EVIDENCE ACQUISITION: We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre. EVIDENCE SYNTHESIS: More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo. CONCLUSIONS: There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

 

Uretroplastica bulbare 1° tempo: Perineostomia

TECNICA:  Incisione perineale ad U rovesciata [foto PER1]. Isolamento dell’uretra bulbare medio-prossimale evitando la sezione del centro tendineo del perineo [foto PER2].  Apertura mediana ventrale dell’uretra, lungo il tratto stenotico e sutura dei margini della spongiosa [foto PER3]. Creazione della perineostomia [foto PER4, PER5].  Catetere Foley 18 Fr (siliconato e scanalato) per 7-10 giorni  non necessariamente collegato al sacchetto della raccolta urine. Medicazione con garze di connettivina legate chirurgicamente [foto PER6]

FOTO PER1FOTO PER1
FOTO PER2FOTO PER2
FOTO PER3FOTO PER3
FOTO PER4FOTO PER4
FOTO PER5FOTO PER5
FOTO PER6FOTO PER6

TEMPO DI ESECUZIONE: Circa 1,5h

TERAPIA: terapia antibiotica mirata in caso di urinocoltura positiva; antibioticoprofilassi con cefalosporina di III generazione in caso di uricocoltura negativa.

GESTIONE PAZIENTE: il paziente deve rimanere a letto per 3 giorni con ghiaccio sul perineo.  Dimissioni in 4° giornata postoperatoria.

MEDICAZIONI: Rimuovere le garze legate chirurgicamente in 3° giornata postoperatoria. Disinfezione della ferita con Betadine soluzione e Garze di connettivina per 20 giorni.

QUANDO IMPIEGARE QUESTO TIPO DI URETROPLASTICA:quando l’uretra peno-bulbare  è molto danneggiata e non fruibile per una chirurgia in tempo unico. Può essere indicata  nei casi di  lichen sclerosus dell’uretra e dei genitali, nonchè nei casi di ipospadia fallita (pazienti plurioperati per ipospadia) e nella ipospadia vergine

COMPLICANZE: sanguinamento<3%, infezione <5%.

PERCENTUALE DI SUCCESSO CENTRO URETRA AREZZO: Casistica aggiornata al 30/06/2015. Effettuate 297  perineostomie. Percentuale di successo 80.1%.

CENTRO URETRA IN ITALIA: èpossibile effetuare una Visita con il Dr. Palminteri o la Dr.ssa Berdondini presso una delle principali sedi: Arezzo, Torino, Milano, Modena, Roma, Napoli, Reggio Calabria, Bari, Brindisi, Palermo, Catania, Messina, Trapani.

APPROFONDIMENTI:

Urethroplasty by scrotal flap for long urethral strictures Blandy JP, et Al. Br J Urol 1968; 40: 261 * No abstract availableNew 2-stage buccal mucosal graft urethroplasty. Palminteri E, et Al.J Urol. 2002 Jan;167(1):130-2.

PURPOSE: Previously buccal mucosal grafts used for repairing adult bulbourethral stricture with the 1-stage dorsal technique has provided a satisfactory outcome in our experience. We present the wider use of buccal mucosal grafts for 2-stage urethroplasty. MATERIALS AND METHODS: A total of 24 men 25 to 60 years old (median age 45) with a complex bulbar stricture underwent 2-stage urethroplasty using a buccal mucosal graft to repair the perineostomy. The primary etiology of stricture was traumatic in 4 cases, inflammatory in 16 and unknown in 4. The 2 x 6 cm. graft was harvested from the inner cheek and sutured to the left margin of the urethral mucosal plate with running 6-zero polyglactin suture. Patients were discharged from the hospital within 3 days with a 14Fr silicone urethral catheter in place. Radiological studies and urethroscopy were done 1 year after closure. RESULTS: A final successful outcome with no recurrent stricture was achieved in 23 of 24 men (92.8%) at a median followup of 18 months (range 13 to 32). In 1 case a urethrocutaneous fistula at the initial radiological assessment closed spontaneously after 14 days of catheterization. No urethral diverticula developed. The mean postoperative peak flow rate is 22 ml. per second (range 18 to 25). CONCLUSIONS: Our new 2-stage buccal mucosal graft urethroplasty may be an excellent technique for complex bulbar urethral stricture disease. Our suggestions may increase usefulness of the 2-stage technique for repairing complex strictures due to the avoidance of classic complications.