Urinary Tract Reconstruction
Dr. Angelo Gousse is fellowship trained training in upper and lower urinary tract reconstruction.
Procedures can include:
The procedure is typically indicated after ureteral trauma or injury of the ureter by cancer or other disease processes. The ureter can be refashioned, reconstructed, and then re-implanted into the urinary bladder On occasion, the urinary bladder has to be reconstructed or moved prior to the reimplantation / reconstruction (Psoas Hitch Procedure or Boari Flap). A typical hospital stay is 3-4 days with a Foley catheter in the bladder for 1 or 2 weeks.
Bladder augmentation using intestinal segments such as colon or small intestines to enlarge the urinary bladder. This procedure is usually performed in patients with neurogenic bladder after spinal cord injury, spina bifida or multiple sclerosis. Urodynamic (bladder testing) may indicate a very high bladder pressure that is dangerous to the kidneys or leakage per urethra (incontinence). The findings are caused by high bladder pressures or involuntary (spastic) contractions. Making the bladder larger by patching a segment (10-20 cm) of intestine into the bladder will decrease the bladder pressure and help protect the kidneys and achieve urinary continence.
On occasion, it is not possible to catheterize per urethra and a catheterizable tube (channel) has to be constructed using intestinal segments or the appendix (Mitrofanoff). An anti-incontinence valve is created using intestines and special surgical techniques to allow the catheter to go in the augmented bladder very readily without allowing urine to leak out. Dr Gousse has performed more than 250 bladder augmentation procedures. The average hospital stay is 7 days after this procedure.
Benign diseases of the urethra which affect urine flow and/or blaldder emptying very often require surgical intervention. Urethral strictures and urethral narrowing (stenoses) are treated by various techniques. The treatment for urethral strictures include numerous options, such as dilation with sounds or plastic dilators, urethrotomy (cutting scar tissue with a knife by going through the penis), stent and open reconstructive surgical techniques. The treatment choice will be dictated by the specific urethral condition or the surgeon’s preference. Although less effective long-term, urethral dilation and direct visual urethrotomy (DVIU) continue to be the most commonly used techniques.
They have a high failure rate with recurrence in at least 50% of patients. Most patients who undergo these procedures require repeated interventions for recurrences. Often the patients progress to surgical repair. Persistent use of dilation or urethrotomy for the treatment of urethral strictures may be the result of the urologist unfamiliarity with the published literature and inexperience with urethroplasty surgical techniques. Open urethral reconstruction (Urethroplasty) is the international gold standard treatment for urethral strictures. Urethroplasty is not a routine operation and a lack of the necessary skills should prompt a referral to a specialist skilled in urethroplasty.
There are two types of Urethroplasty. Many surgical techniques with or without grafts have been developed to allow the aesthetic reconstruction of the glans and the penis while repairing the strictured areas.
Basically, the surgical technique for urethral reconstruction is selected according to the cause and location of the urethral stricture disease. The choice between an anastomotic versus a tissue transfer technique is aided by a radiograph (retrograde urethrogram), surgeon experience and preference. The choice must, in addition be based on the proper anatomic characteristics of the penile tissues to ensure flap or graft take and survival. Urethroplasty is a open surgical procedure for urethral reconstruction to treat urethral stricture. Urethroplasty can be performed by 2 basic methods; Excision and anasmotomis (primary repair) which involves complete excision of the narrowed part of the urethra and the subsequent rejoining of the proximal and distal patent luminal segments. The second method of Urethroplasty utilizes tissue transfer (flaps) or graft technique. In this method, tissue is grafted from penile foreskin, or buccal (inner lining of the mouth) mucosa and is used to enlarge the caliber of the strictured (narrowed) segment of the urethra. Dr Gousse prefers buccal mucosa graft as his tissue transfer(graft technique) because the graft material is abundant, well tolerated, cosmetic, and successful in most cases. Urethroplasty is typically performed under general or spinal anesthesia. Selected patients may be discharged home on the day of the surgery. Many others will be in the hospital for a day or two. The patients typically wears an indwelling urethral Foley catheter for 2- 3 weeks to allow the repair to heal. After catheter removal, the patients are followed with clinical symptoms, urine flow rate, and post void residual volumes to ensure bladder emptying. Many patients will be able to enjoy baseline sexual function and father children after surgery.
Like all surgical procedures, the results of urethroplasty are not 100%. A recurrence urethral stricture rate of 10 % can be expected long-term. Patients with pelvic fracture associated urethral stricture and prostate involvement associated strictures have the highest recurrence rate. Erectile dysfunction is also most commonly seen in this sub-category of patients.