Atlas of Urethroplasty Rajesh Gulia, Richard Santucci
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Editor Rajesh Gulia MBBS MS DNB (Urology-NBC) MNAMS (Genitourinary Surgery) Senior Specialist Chief (Urology) and Head Reconstructive Urology, Unit II Director Kidney Center, Sector 34A Chandigarh, India Co-Editor Richard Santucci MD FACS Clinical Professor Michigan State University College of Osteopathic Medicine Specialist-in-Chief Department of Urology The Detroit Medical Center Director, The Center for Urologic Reconstruction Detroit, MI, USA Foreword Sanjay B Kulkarni
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5Dedicated to
In the memory of Professor Hattangadi Shashidhar Bhat January 21st 1921–November 19th 2010
The one person who has shaped me into what I am today. He is none other than my “Guru”—Professor HS Bhat. It is from him, I learnt how to respect the human urethra. Apart from the many golden one liners, I would like to mention one. Regarding female urethra, he used to say “it is an outlet for many a problems in the ladies, so ensure that it is patent, lest you face the fallbacks of a blocked drain”.
About urethral stricture, he would often say “traumatic strictures are curable but inflammatory strictures can only be palliated”. On his response to the results of various urethroplasties, he would say “you can say a urethral stricture is cured only if it has a dilatation-free life of at least 10 years”. In tune with his humane touch and the importance of SPC, he would say “after the age of 75 years, a patient of stricture urethra has no business to pass urine per urethra, he will be a burden on his family. Let him live happily on an SPC”. He would always say place yourself in the patient's shoes and you can never go wrong!
Rajesh Gulia
7Contributors 9Foreword
I wish to congratulate my friends Dr Rajesh Gulia and Dr Richard Santucci for introducing Atlas of Urethroplasty.
Urethral stricture disease is known to mankind for more than 5000 years. In the past, patients were treated by dilation. The initial enthusiasm of direct visual internal urethrotomy (DVIU) slowly waned over a period of time. As the long-term success rates were not favorable. Now urethral stricture is considered an open surgical disease.
The book has been a hard work and contribution from renowned reconstructive urologists around the globe. The book has 15 chapters starting from the basics of anatomy to the complex procedures and tissue engineering. Each chapter is crafted by experts in their field. It narrates the detailed description of steps for performing a successful surgery. The book also provides a DVD on surgical techniques.
Urethral stricture disease is a challenging issue. Urethra is a nonforgiving organ and delicate care needs to be taken while performing urethroplasty. Failure of urethral surgery directly affects the quality of life of patient and family.
More urologists are diverting their attention to reconstructive urology.
Posterior urethroplasty after pelvic fracture urethral injury needs expert management. I suggest that all urologists should have adequate knowledge of standard steps of anastomotic urethroplasty in posterior urethra. I have detailed the steps in my chapter for reference. However, failures of surgery in pelvic fracture urethral distraction defect (PFUDD) are complex and hence it is advisable for urologists to personally train under experts for management of PFUDD surgery.
I believe that when there exists two options/surgeries for one problem, it means there is scope of improvement. It means no procedure is perfect. Today in reconstructive urology, we are moving towards standardization. For example, buccal grafts are widely recommended. Flaps are used rarely when there is problem of ischemia. Ventral onlay is performed for proximal bulbar strictures. Dorsal onlay buccal graft urethroplasty is widely practiced for bulbar strictures. Anastomotic urethroplasty is preferred mainly in traumatic strictures. Penile strictures can be approached by circumcision or by minimally invasive cosmetic perineal approach with invagination. One stage procedures are more successful than 2 or 3 stage procedures.
These clear concepts will assist urologists to perform majority of urethroplasty.
The basis of the book is to provide simple solution for complex urethral stricture disease. I am sure that it will help all urologists to have clear understanding of commonly performed urethroplasties.
Sanjay B Kulkarni
ms frcs (glasgow) dip urology (london)
Professor and Chief
Department of Urology
Center for Urethral Reconstruction and Indian School of Urethral Surgery
Pune, Maharashtra, India
Need for Such a Book
Actually, there was no need of a separate book on stricture urethra. Not until then! When approached for writing a book in urology, I could not think of anything more close to my heart than urethroplasty; and while on this project, I realized–Not until now! Times have changed.
The level of specialization now talks of anterior urethral, bulbar urethral and posterior urethral surgeons. Can we be left behind? We have got to know more and more of less and less. We cannot restore the factory settings of any machine (human body being the most complex one manufactured by God) but we, can become the 2nd factory itself where such machines come for repair. Having been to one of the automobile factories, one wonders at the level of standardization. No wonder they are able to roll out such mean machines of perfection to the likes of Lamborghinis’ and the Audis’. Our aim as urethral engineer is to standardize each procedure down to the finest detail much akin to the assembly line system. This will enable to significantly cut down the operating time and unnecessary tissue handling. All this translates into better results. In the beginning of my endeavor towards perfection, on seeing recordings of my own surgeries, I was surprised at the number of unnecessary steps and movements. Now, I have been able to engineer my own assembly line with reasonable time precision. And, in this small journey of mine, I must thank Professor Kulkarni, who never fails in stimulating your gray cells. Our aim should be to work at least at a 6 sigma level.
We must also realize that there are “n” number of procedures for treating “n” types of strictures and each has good results in the hand of their proponents. Our aim is not to confuse the young budding urethral engineer into the maze of the number of procedures available, but to present before him 10% of the procedures which if mastered can cure more than 90% of the strictures. The other 10% can be taken care of by the other 90% procedures available. Urethral stricture disease does not involve any hi-tech technology or implants. Hence, the absence of any company driven bias/sponsorship. A urethral surgeon is a “poor” surgeon; the only satisfaction is the smile on the face of a patient when he keeps on voiding without any assistance—day after day, month after month, year after year. This puts a greater burden of moral responsibility on our shoulders in presenting this complex problem with utmost simplicity and clarity.
We must always constantly challenge our gray cells. I strongly believe that the best way to grow is to separately keep an hour or so daily when you can do the thinking cap. Read about your area of interest, see your own procedures, etc. We do come out with certain concepts, ideas which have proved to be logical and useful in certain cases (not necessary for it to have been subjected to the concept of evidence-based medicine). Some ideas may sound funny/bizarre/awkward at the moment, but could be the triggering point of another blast waiting to happen in some destined neurons.
The most exciting phrase to hear in science, the one that heralds new discoveries, is not “Eureka!” but “That's funny…”
— I Asimov
A word of advice for the young urethral surgeons–Press on. Nothing in the world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education alone will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent—(C. Coolidge).
Rajesh Gulia
On a personal level, I would like to offer my sincere thanks to the support given to me by my colleague urologists—Dr Manoj Sharma and Dr Virendra Dhankhar. Had it not been for them, this project would not have seen the light of the day. My Co-editor Professor Richard Santucci has been the guiding force. His promptness in dealing with any deadline is remarkable. Dr Santucci would like to thank his family—Christine, Lauren, and Alison for their perseverance and support. “We all know it could not be done without you.”
All the contributors were very helpful and prompt in their respective contributions, I have my greatest regards for them.
With love to Pinki, Kabir and Monchu, who always pushed me hard and gave me constant encouragement to excel. Not to speak of the family time lost which they sacrificed for the sake of this book.
Last but not least, I have no words for my publisher M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who very patiently waited for the project to finish.
Rajesh Gulia
19List of Abbreviations ACSM
Acellular Corpus Spongiosum Matrix
Buccal Mucosal Graft
Balanitis Xerotica Obliterans
Clean Intermittent Catheterization
De-epidermized Dermis
Direct Vision Internal Urethrotomy
Extracellular Matrix
Erectile Dysfunction
Food and Drug Authority
Kidney Ureter Bladder
Lichen Sclerosis
Lichen Sclerosus et Atrophicus
Lower Urinary Tract Symptoms
Micturating Cystourethrogram
Mega Hertz
Magnetic Resonance Imaging
Optical Internal Urethrotomy
Operating Room
Progressive Perineoabdominal Approach
Pelvic Fracture Urethral Disruption Defect
Polyglycolic Acid
Polyhydroxybutyric Acid
Polylactic Acid
Poly (lactic-co-glycolic acid)
Retrograde Urethrogram
Radical Retropubic Prostatectomy
Squamous Cell Carcinoma
Small Intestine Submucosa
Split Thickness Skin Graft
Transurethral Resection of the Prostate
Urine-derived Stem Cells
Voiding Cystourethrography
External Radiation Therapy
Urethroplasty is more art than science. Even in this modern day of molecular biology, routine space travel and ubiquitous computing, the field of urethroplasty is still a craft. It is performed full-time by a surprisingly small group of surgeons, perhaps 40(?), worldwide. However, we have calculated that at least in the United States, less than 2% of the urethroplasties that should be done are actually done. Most patients are treated with proven ineffective treatments: endlessly repeated courses of urethral dilation and urethrotomy. In the rest of the world, the number of urethroplasties performed is probably even lower. I need to upgrade the treatment of urethral stricture from “craft” to “science”.
I have created the “Atlas of Urethroplasty” for just this reason. I desire to communicate the tools of urethroplasty to a wide audience, with the idea of revealing the secrets of expert craftspeople. I have chosen a world-class panel of authors to achieve this result. In this text you will learn the basic techniques (graft onlay, anastomotic, fasciocutaneous and Johanson urethroplasties) and how to apply them. Also, I have included intraoperative videos (more still are available on and have strived to provide the tools that expert and novice surgeons alike can use to advance the field, and improve life for their patients.
Richard Santucci