Managing the Post Radiation Bladder Neck and Proximal Urethral Stricture Challenges
Jay Simhan, MD, FACS, explores the challenges of post-radiation bladder neck and proximal urethral strictures.
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Topic: Urethral Strictures
Bulbar Urethroplasty: What the Patient Should Know about Complications
Margit Fisch, MD, FEAPU, FEBU, explores informing patients before urethroplasty, various surgical techniques, and possible complications.
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Paclitaxel Coated Balloons (Optilume) Demystified Knowing When To Say Yes, No, or Wait
Jay Simhan, MD, FACS, explores the role of Paclitaxel-coated balloons, specifically Optilime, in treating urethral strictures.
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Mechanism of Urethral Injury in Children and Anatomical Limitations for Urethral Reconstruction
Margit Fisch, MD, FEAPU, FEBU, explores urethral stricture disease in children, emphasizing differences compared to adults.
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Female Urethra Stricture Disease: Evaluation and Surgical Management
Oluwarotimi S. Nettey, MD, MHS, discusses the complexities of female urethral stricture disease, which, although less common than in men, often goes underdiagnosed due to its non-specific symptoms and rarity.
In this 18-minute talk, Dr. Nettey shares this disease often coincides with lower urinary tract symptoms. While its exact causes are largely idiopathic, medical procedures like catheterization, radiation, and surgeries, as well as conditions like vaginal atrophy in postmenopausal women, can increase the risk.
Diagnosis typically involves cystoscopy, with additional imaging options providing insights into stricture location and bladder morphology. Uroflowmetry and video urodynamics offer further understanding of urinary dynamics, helping tailor treatment approaches. Non-surgical management includes vaginal estrogen and corticosteroids.
Nettey shares that endoscopic dilation is a first-line treatment but has diminishing returns with repeated procedures, while open surgical repair becomes essential in complex cases. She underscores the need for individualized management and referrals to reconstructive specialists for challenging cases, emphasizing the importance of a methodical approach in addressing this underrecognized condition.
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Management of Posterior Urethral Strictures
Shyam S. Sukumar, MD, provides an in-depth exploration of managing posterior urethral strictures, focusing on the anatomical and procedural complexities unique to posterior cases. Throughout this 16-minute presentation, Dr. Sukumar shares drawings and images to illustrate the nuanced approaches necessary for managing posterior stenosis.
Stress incontinence becomes a crucial consideration, especially in patients with radical prostatectomy histories. Sukumar emphasizes the need for a comprehensive preoperative assessment to accurately gauge stricture extent and plan the repair approach. For surgical reconstructions, Dr. Sukumar highlights differing procedures from anastomotic urethroplasty and flap procedures, depending on patient need.
Sukumar believes posterior urethral stricture repair demands flexibility in approach and a readiness to adapt intraoperatively based on the challenges presented. Mastery of various reconstructive techniques and a patient-specific approach ensure optimal outcomes, especially in these anatomically and procedurally demanding cases.
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Transmeatal Urethral Surgery: Distal, Proximal, and Short Stricture Repair
J. Nicholas Warner, MD, outlines techniques for managing anterior urethral strictures through endoscopic urethroplasty. In this 8-minute presentation, Dr. Warner discusses different approaches—distal, proximal, and management of short strictures.
Dr. Warner shares cases, including images and surgical videos illustrating the steps for each approach. He discusses patient criteria for each methodology and success rates.
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Transurethral Incision and Transverse Mucosal Realignment
J. Nicholas Warner, MD, discusses advancements in endoscopic urethroplasty, focusing on techniques for addressing bladder neck and vesicourethral anastomotic stenosis. In this 7-minute presentation, which includes a video of a procedure, Dr. Warner outlines the transurethral incision and transverse mucosal realignment technique, emphasizing the initial scar identification, resection, and dilation strategies.
Warner asserts that advancements in endoscopic techniques have shown promising results in treating urethral strictures, with a focus on optimizing patient outcomes through refined surgical strategies.
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Endoscopic Management Including Drug-Coated Balloon – Optilume
Ty Higuchi, MD, PhD, explores the endoscopic management of urethral strictures, focusing on the drug-coated balloon technology. In this 10-minute presentation, Dr. Higuchi shares that urethral strictures, common in urology practices, are traditionally treated with dilations and direct vision internal urethrotomies (DVIU). Data shows that DVIU has a success rate of about 50% on the first attempt, with diminishing returns on repeated procedures. Adjunctive treatments like steroids or self-dilation have been explored but show limited efficacy in preventing stricture recurrence.
Higuchi highlights a newer approach with the FDA-approved drug-coated balloon (Optilume). He shares studies such as the Robust I and II trials, which have demonstrated promising results. Dr. Higuchi recommends the drug-coated balloon for ease of use and minimally invasive nature.
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Posterior Stenosis – Post-Radiation or Anti-BPH Procedures
Dmitriy Nikolavsky, MD, discusses urethral stricture and stenosis management following radiation and anti-BPH procedures, highlighting surgical challenges, outcomes, and the evolution of treatment strategies.
In this 11-minute presentation, Nikolavsky explores the differences in stricture occurrence across treatment types. Surgical approaches are tailored based on oncologic status, patient preference, and local tissue health. Buccal mucosal grafts for dorsal urethroplasty are highlighted as a promising technique. Notably, dorsal-only urethroplasty has demonstrated comparable success to EPA with a lower incidence of postoperative incontinence.
Dr. Nikolavsky emphasizes the difficulties of traditional excision procedures in radiated fields, proposing dorsal-only urethroplasty as a better alternative due to its minimal disruption of adjacent structures. He shares evidence from multi-institutional studies that support its efficacy.
With a call to challenge established dogmas, Nikolavsky underscores the need to refine guidelines and expand the use of innovative approaches like dorsal urethroplasty to improve patient outcomes.
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Reconstruction of Complex Upper and Mid Ureteral Strictures with Buccal Mucosa Graft Ureteroplasty
Ziho Lee, MD, focuses on using buccal mucosa grafts in ureteral reconstruction and highlights their value in complex cases. Buccal mucosa grafts offer a practical alternative when standard resection and anastomosis are not feasible.
In this 11-minute presentation, Dr. Lee describes onlay grafts, where the anterior surface of the ureter is slit and patched with the graft, and augmented anastomotic repairs for more severe cases with obliterated segments. He shares a short video of both techniques.
Dr. Lee emphasizes the importance of minimizing tissue manipulation and dissection, particularly in cases with fibrosis. Strategies like measuring defects with precision and securing grafts using Monocryl sutures are discussed for graft placement. He recommends using omental wrapping or attaching grafts to the psoas muscle to ensure stability and promote vascularization, especially in retroperitoneal cases.
Penile/Panurethral and Fossa Navicularis Strictures
Dmitriy Nikolavsky, MD, focuses on penile strictures and discusses their etiology, anatomical considerations, and treatment options. In this 10-minute presentation, Dr. Nikolavsky shares that current surgical techniques have shifted from multi-stage procedures to single-stage approaches using buccal mucosal grafts, which have shown improved success and lower complication rates. Key procedures discussed include the Asopa and Kulkarni techniques.
The discussion highlights evolving strategies for managing urethral strictures, underscoring a trend towards less invasive, more effective interventions prioritizing patient outcomes and satisfaction. The advancements in this field indicate a significant move towards transurethral approaches, with ongoing research aiming to refine and improve surgical techniques.
