Bulbur Urethroplasty -Dr. Sanjay Kulkarni' write up

• 11 May 2021 09:59:29 PM
• |Reconstructive Urology

Dear All,

Comments(8)

• 

  Dr Sanjay Balwant Kulkarni

  12 May 2021 08:33:44 AM

  Dear Friends

  There is lot of discussion about the best way to treat the bulbar urethral strictures, the most common site for urethral strictures. We perform around 500 Urethroplasties per year, apart from China we have the largest series in the world.

  We just counted and found that more than 100 Urologists from across the world have visited our centre in last 10 years!

  We have commented on the systematic review published recently and have added our algorithm. Please send constructive criticism.

  Sanjay Kulkarni and Team

• 

  Dr. Roy Chally

  12 May 2021 10:07:33 PM

  Splendid write up. Continue the good work. I have one query. 

  In the paper you mentioned that, end to end anastomoses is the choice of treatment in completely obliterative traumatic strictures, with history of multiple failed previous attempts to repair and in elderly with many co-morbidities. 

          Is the length of urethral loss and vascularity of the distal urethra in such situations a concern. How do you decide the selection criteria for end to end anastomoses in such cases. Any role for substitution uerthroplasty ? In elderly with many co-morbidities when will you consider perineal urethrostomy?
  

     

• 

  Dr Sanjay Balwant Kulkarni

  13 May 2021 08:37:41 PM

  Dear Dr Roy Chally

  Thanks a lot.

  After bulbar transection for non traumatic stricture, the distal urethra may loose vascularity if the retrograde blood flow is inadequate as in hypospadias, Vascular ED.

  Each time we transect we resect and excise 1cm Bulbar urethra and spatulate 1.5cm on opposite sides, 2.5cm urethra is shortened. If we transect and excise 2cm Bulbar urethra and spatulate we loose 3.5cm urethra.

  So we transect bulbar urethra only for trauma may be 3-4 times a year, and we perform 500 urethroplasties per year! 

  I utilise Methylene Blue Color Spongiography technique to decide the contunity of spongiosa. I place needle above and below the stricture into spongiosa and inject dilute MB distally and check if the due is coming out through the proximal needle. No dye indicates significant spongiofibrosis and I will transect. Dye in the proximal needle suggests contunity of spongiosa and I will not transect and augment the urethra.

  In elderly male with significant morbidities I will offer perineal urethrostomy. But as the age advances it is difficult to sit down due to knee pain and one has to find a toilet   and it may be difficult to find it quickly. I rarely see a patient with  perineal urethrostomy which does not need dilation. So in my practice permanent perineal urethrostomy is the last choice after multiple failed urethroplasties.

  
  

  
  

  
  

• 

  Lalit Shah

  17 Jun 2021 08:32:03 PM

  We believe everything depends on on table findings.

  Most of the so called short bulbar urethral strictures, are in fact not traumatic and have pretty good vascular supply as seen on bleeding spongiosum on table!!

  Moreover the results are same for dorsal and ventral approach for bulbar urethra covered with bulbospongiogus muscle.

  No justification at all for going ahead with dorsal approach and causing more dissection, more possible bleeding, more possible fibrosis, more possible stricture!!

  If stricture limited to proximal bulb covered with muscle, don’t spoil by considering dorsal approach unnecessarily. 🙏🙏🙏

• 

  Lalit Shah

  17 Jun 2021 08:32:07 PM

  We believe everything depends on on table findings.

  Most of the so called short bulbar urethral strictures, are in fact not traumatic and have pretty good vascular supply as seen on bleeding spongiosum on table!!

  Moreover the results are same for dorsal and ventral approach for bulbar urethra covered with bulbospongiogus muscle.

  No justification at all for going ahead with dorsal approach and causing more dissection, more possible bleeding, more possible fibrosis, more possible stricture!!

  If stricture limited to proximal bulb covered with muscle, don’t spoil by considering dorsal approach unnecessarily. 🙏🙏🙏

• 

  Lalit Shah

  17 Jun 2021 08:32:09 PM

  We believe everything depends on on table findings.

  Most of the so called short bulbar urethral strictures, are in fact not traumatic and have pretty good vascular supply as seen on bleeding spongiosum on table!!

  Moreover the results are same for dorsal and ventral approach for bulbar urethra covered with bulbospongiogus muscle.

  No justification at all for going ahead with dorsal approach and causing more dissection, more possible bleeding, more possible fibrosis, more possible stricture!!

  If stricture limited to proximal bulb covered with muscle, don’t spoil by considering dorsal approach unnecessarily. 🙏🙏🙏

• 

  Lalit Shah

  17 Jun 2021 08:32:15 PM

  We believe everything depends on on table findings.

  Most of the so called short bulbar urethral strictures, are in fact not traumatic and have pretty good vascular supply as seen on bleeding spongiosum on table!!

  Moreover the results are same for dorsal and ventral approach for bulbar urethra covered with bulbospongiogus muscle.

  No justification at all for going ahead with dorsal approach and causing more dissection, more possible bleeding, more possible fibrosis, more possible stricture!!

  If stricture limited to proximal bulb covered with muscle, don’t spoil by considering dorsal approach unnecessarily. 🙏🙏🙏

• 

  Lalit Shah

  17 Jun 2021 08:32:17 PM

  We believe everything depends on on table findings.

  Most of the so called short bulbar urethral strictures, are in fact not traumatic and have pretty good vascular supply as seen on bleeding spongiosum on table!!

  Moreover the results are same for dorsal and ventral approach for bulbar urethra covered with bulbospongiogus muscle.

  No justification at all for going ahead with dorsal approach and causing more dissection, more possible bleeding, more possible fibrosis, more possible stricture!!

  If stricture limited to proximal bulb covered with muscle, don’t spoil by considering dorsal approach unnecessarily. 🙏🙏🙏