Dr Sanjay Balwant Kulkarni
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DVIU Vs Urethroplasty: by Sanjay Kulkarni and Pankaj Joshi
Jing Shen published an article in BMC Urology about cost effective comparison between DVIU and Urethroplasty. The conclusion was DVIU is more cost effective.
Every patient in the world, irrespective of type of Health Care or Finances, deserves the correct treatment. Finances should not govern the patient care. Recurrent admissions, multiple surgical procedures burden the healthcare. If there is a single surgical procedure which can offer long term success, it should be performed. This holds true for DVIU versus Urethroplasty.
Role of DVIU:
DVIU is to be avoided in the penile and membranous urethra.
The ideal indication of performing DVIU today is for short segment (<1 cm) non traumatic bulbar urethral stricture.
Performing repeated DVIU makes the stricture longer and dense. Santucci et al studied the long-term success of DVIU. Success rates were no higher than 9% in this series for first or subsequent urethrotomy during the observation period. Most of the patients in this series will be expected to experience failure with longer follow-up and the expected long-term success rate from any (1 through 5) urethrotomy approach is 0%. Urethrotomy should be considered a temporizing measure until definitive curative reconstruction can be planned (1).
Ideal Instrument: DVIU for anterior urethra should be performed by cold knife. Lasers should be used for DVIU for anastomotic strictures after failed pelvic fracture urethral surgery.
Site of DVIU: The concept of DVIU is to create a gap between the epithelium and hope for primary healing. In bulbar urethra, sponge is most wide at 6 0 Clock position. At 12 O clock position, there are the corpora. DVIU at 12 o Clock position can injure the corpora, lead to bleeding and rarely ED. At 6 o clock there is wide sponge. This allows the urethral margins to expand and allow healing. Turner Warwick, Father of Urethroplasty recommended performing DVIU between 4-8 oâ€™clock.
PANKAJ JOSHI20 May 2021 04:27:40 PM
We appreciate the comments by Dr Venugopal sir .Recurrent DVIU makes the stricture long and dense (Picture attached)Subsequent Urethroplasty may become challenging.Long term results of Buccal graft augmentation Urethroplasty are high .Reference:Barbagli G, Kulkarni SB, Fossati N, Larcher A, Sansalone S, Guazzoni G, Romano G, Pankaj JM, Dell'Acqua V, Lazzeri M. Long-term followup and deterioration rate of anterior substitution urethroplasty. J Urol. 2014 Sep;192(3):808-13. doi:
Dr. Roy Chally21 May 2021 08:16:31 AM
Ideally one attempt in passable non traumatic short segment structure, DVIU advised. Depth of cut when bleeding was seen decides the outcome. As mentioned repeated attempts are not helpful.Traditionally we advised cut at 12 clock position because we want to avoid extravasation. The bulbar urethra is wide at 6 clock only in position close to the perineal body. Only in very experienced hands incision in 6 clock position advised. Lateral cuts has a higher risk of injuring the corporal arteries.In post traumatic anastomotic structureLaser ablation are needed for success. Laser incision alone will not work.
Dr. Anil Takvani23 May 2021 07:55:40 AM
Dear Dr. Roy Chelly sir,Thanks for your valuable inputs.We would like to request you to elaborate on laser ablation for failed anastomotic post trauma strictures....thanks
Dr. Roy Chally23 May 2021 01:12:03 PM
I had a young patient with recurrent post traumatic structure in the bulbo-membranes area in the 90s.? The structure segment was narrow <2cm. Repeated DVIU did not work. I had Nd Yag laser. This was used for ablation. A wide passage was created with ablation, all round the structure segment. He is passing urine normally for the last 20 years. I know that this is will not qualify for scientific evidence. Hope someone will take this up for a study.
Venugopal P20 May 2021 09:01:37 AM
Historically, it was said that â€˜once a Urethral Stricture, always a strictureâ€™. Periodic Dilatation was the mainstay in treating strictures and every OT of surgeons were followed by patients waiting for what was called â€˜Rapid Dilatationâ€™ for their strictures. My father, an eminent surgeon of the past taught us that there were 3 types of Urethral Strictures namely â€˜Passable, Impassable and Impissableâ€™. The passable used to be managed by periodical dilatation. The Impossible was started with Filiform dilatation to be followed by repeat regular dilatations and the last needed diversion as the initial step followed by External Urethrotomy famous in those days. Times changed with many performing â€˜Two stage Urethroplastiesâ€™ prior to arrival of â€˜Single Stage Urethroplasties for Bulbar urethral Stricturesâ€™.
I have been an ardent follower of Visual Internal Urethrotomy ever since Sachse introduced his Optical Urethrotome wat back in 1974. I got my Urethrotome during the initial years of its introduction and started using it extensively (on hindsight I should say rather indiscriminately). Over a period of time well into 1980â€™s I did practice this procedure rather extensively. But recurrences and redoâ€™s made me realize that the procedure was not as great as it was being propagated. I have even done 3 to 4 VIUâ€™s on patients. In probably early 1990â€™s, I more or less abandoned this procedure and reverted back to Urethroplasties as it was being performed at that time with Excision and End to End Anastomosis as the main procedure for Short segment Bulbar strictures. This, of late has been replaced by various techniques of Substitution Urethroplasty.
I was rather taken aback on reading this article wherein the authors found DVIU is more cost effective as against urethroplasties
There are many Urologists in India still performing DVIU for Bulbar Urethral Strictures. As suggested by Sanjay, there are only few indications for DVIU and that too performed once. We were all taught that the cut should extend from pink zone proximally to pink zone distally across the white zone, thereby cutting the urethra over a long length. This resulted, more times than not resulting in a restructure of longer length. Sanjay suggest that we cut the stricture at 60 Clock Position, while most of us performed it at 120 Clock Position.
I began to say that probably VIU using Sachse Urethrotome should be â€˜Relegated to Urological Historyâ€™. This was objected by our Urological community, as mentioned there were and are many who favour DVIU even today.
For the benefit of our members, I am providing Two Chapters taken out of the book â€˜Textbook of Male Genitourinary Reconstructionâ€™ Ed: Francisco E. Martins, Sanjay B. Kulkarni and Tobias S. KÃ¶hler, 2020.
One is on â€˜Substitution Urethroplasty for Bulbar Urethral Stricturesâ€™ by Akio Horiguchi and Masayuki Shinchi where in all techniques of Substitution as practiced today are described.
The other Chapter that We ned to have a detailed knowledge is the chapter by Soo Woong Kim and Hyun Hwan Sung on â€˜Predictors of Urethral Stricture Recurrence After Urethroplastyâ€™. Section 184.108.40.206 addresses the present stand on DVIU briefly.
I am sure Sanjay and Pankaj will clear most of the cobwebs still existing as what is ideal as regards the various issues associated with treatments of Bulbar Urethral Strictures.
With warm Regards,