estrechez uretral
DESCRIPTION
Espongiofibrosis, etiologia, uretrografia retrograda, estrechez uretral anterior y posterior, dilatacion uretral, uretrotomia interna, uretroplastia por anastomosis vs substitucion, injerto uretral, reconstruccion escalonada vs primariaTRANSCRIPT
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Estrechez Uretral
Katherine Henríquez
UROLOGÍA
Panamá, 13 junio 2012
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Epidemiología
Incidencia ↑ con la edad
Lineal hasta los 55 años
Abrupto después de los 55 años
Enfermedad vascular periférica produce isquemia uretral
Raro en mujeres
Incidencia sintomática 1:2000 hombres
McMillan A, Pakianathan M, Mao JH, Macintyre CCA. Urethral stricture and urethritis in men in Scotland. Genitourin Med 1994;70:403–5.Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol 2007;177:1667–74.
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Anatomía Uretral
Localización de uretra en relación al cuerpo esponjoso
Peneana → central
Bulbar → excéntrica
(dorsal)
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Anatomía Uretral
Irrigación sanguínea dual y bilateral
SISTEMA DE VASCULATURA FASCIOCUTÁNEA
Proximal → arteria penil
Distal → arteria dorsal del pene
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tral Espongiofibrosis
Contracción de la cicatriz del tejido eréctil del cuerpo esponjoso reduce lumen uretral
Uretra Proceso Resultado
Anterior* Cicatrización Constricción
Posterior Obliteración Estenosis
Fisiopatología
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Fisiopatología
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Est
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tral Cualquier proceso que lesione epitelio uretral o cuerpo
esponjoso subyacente que resulte en cicatrización
Etiología
Traumático (mayoría) Inflamatorio
• Trauma a horcajadas
• Iatrogénico
• Uretritis gonocóccica
• Liquen escleroso / balanitis xerótica obliterans
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Etiología
D. Andrich, A. Mundy. What is the Best Technique for Urethroplasty? European Urology 54 ( 2008 ) 1031–1041
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Etiología
Iatrogénica (por instrumentación)
Resección transuretral 41%
Cateterización prolongada 36.5%
Cistoscopia 12.7%
Hipospadia previa 6.3%
Prostatectomía radical 3.2%
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Etiología
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Clínica
Síntomas urinarios obstructivos
Infección de vías urinarias• Prostatitis• Epididimitis
• ↓ calibre y fuerza• retención urinaria
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tral Características de la espongiofibrosis
Localización
Longitud
Profundidad
Densidad
Evaluación
UretrografíaUretroscopiaUltrasonido
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tral Uretrografía retrógrada
Estática
Dinámica
Uretroscopia / cistoscopia flexible
Retrógrado
Anterógrado (cistostomia)
Ultrasonido penil
Evaluación
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Uretrografía Retrógrada
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Uretrografía Retrógrada
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Uretrografía Retrógrada
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Ultrasonido penil
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Evaluación
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Evaluación
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Clasificación
Choiu RK, Anderson JC, Tran T, Patterson RH, Wobig R, Taylor RJ (1996) Evaluation of urethral strictures and associated abnormalities using high resolution and color Doppler ultrasound. Urology 47:102–107
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Evaluación
Evaluación endoscópica del área proximal y distal a la estrechez uretral
• Constricción inaparente por hidrodilatación durante micción
• Puede continuar obstrucción luego de reconstrucción
• Defuncionalizar uretra con drenaje suprapúbico por 6-8 semanas
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Tratamiento
Dilatación Uretral
Uretrotomía Interna
Uretroplastia
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Tratamiento
Reconstrucción “escalonada”
Uretroplastía Primariavs
Rourke KF, Jordan GH. Primary urethral reconstruction: the cost minimized approach to the bulbous urethral stricture. J Urol 2005;173:1206–10.Greenwell TJ, Castle C, Andrich DE, MacDonald JT, Nicol DL, Mundy AR. Repeat urethrotomy and dilatation for the treatment of urethral stricture are neither clinically effective nor cost-effective. J Urol 2004;172:275–7.
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tral META: Ensanchar la estrechez sin producir mayor
cicatrización
Uretrorragia durante dilatación → desgarro de la estrechez uretral
Utilizar método menos traumático
Catéteres de dilatación uretral con balón
Dilatación Uretral
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Dilatación Uretral
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tral Abre la estrechez por incisión transuretral
Liberación de contractura de la cicatrización y curación con lumen uretral ensanchado
Epitelización completa antes de contractura de herida
Uretrotomía Interna
Extensión del lumen uretral estrecho predice el éxito de la uretrotomía interna:
Entre mayor el porcentaje de estrechez, peor resultado
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Uretrotomía Interna
Sin visión directa: uretrótomo de Otis
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Uretrotomía Interna
Con visión directa: corte frío
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Uretrotomía Interna
Con visión directa: láser
• Dióxido de carbono: riesgo de émbolo
• Argón y Nd:YAG producen necrosis tisular en tejido periférico
• KTP y holmium:YAG por contacto directo de corte y vaporización
• Excimer laser en estudio
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tral Técnica
Incisión simple en radio 12
Porción más delgada en un corte axial del cuerpo esponjoso: radio 10 a 2
Distancia entre pared uretral anterior y cuerpo esponjoso es corta en la uretra bulbar
Uretrotomía Interna
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Uretrotomía Interna
Fuerzas opuestas a la contracción de herida
Cateterización uretral
Tasa fallida similar entre 6 semanas y 3 a 7 días
Endoprótesis uretral implantable
Removible a los 6 meses – 1 año
Permanente
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Endoprótesis Uretral
• Pueden migrar y producir dolor perineal• Reacción hipertrófica si hay piel implantada en uretra• Contraindicado en lesión uretral por fractura pélvica
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Uretrotomía Interna
Resultados Tasa de éxito curativo 30-35%
No aumenta con segunda uretrotomía interna
Estrechez bulbar < 1.5 cm sin espongiofibrosis densa ni profunda tiene tasa de éxito a largo término del 74%
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Uretrotomía Interna
Complicaciones Recurrencia de la estrechez uretral (más común)
Uretrorragia
Extravasación del líquido de irrigación en tejido periesponjoso
Disfunción veno-oclusiva cavernosa
Por fístula entre cuerpo esponjoso y cavernoso
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Uretrotomía Interna
Steenkamp JW, Heyns CF, De Kock ML (1997) Internal urethrotomy versus dilation as treatment for male urethral strictures: A prospective, randomized comparison. J Urol 157:98–101
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Uretrotomía Interna
Steenkamp JW, Heyns CF, De Kock ML (1997) Internal urethrotomy versus dilation as treatment for male urethral strictures: A prospective, randomized comparison. J Urol 157:98–101
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Uretrotomía Interna
Steenkamp JW, Heyns CF, De Kock ML (1997) Internal urethrotomy versus dilation as treatment for male urethral strictures: A prospective, randomized comparison. J Urol 157:98–101
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Tipos de Uretroplastia
Anastomosis
Substitución
AbordajesEstrechez
corta
Estrechez larga
• Bulbar o peneana• Colgado de piel o injerto de mucosa oral• Estricturotomía dorsal o ventral
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Uretroplastia
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Reconstrucción Abierta
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Completa excisión del área de fibrosis
Reanastamosis primaria de los extremos normales de la uretra anterior
Espatulación
Libre de tensión
Movilización vigorosa del cuerpo esponjoso
Uretroplastia Anastomótica
Anastamosis
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Uretroplastia Anastomótica
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Uretroplastia Anastomótica
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Uretroplastia Anastomótica
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Eltahawy EA, Schlossberg SM, McCammon KA, Jordan GH (2005) Long term follow up for excision and primary anastomosis in anterior urethral strictures. J Urol 173(Suppl.):87Santucci RA, Mario LA, McAninch JW (2002) Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol 167:1715–1719
Uretroplastia Anastomótica
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Uretroplastia Anastomótica de Aumento
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Uretroplastia Anastomótica de Aumento
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Guralnick ML, Webster GD. The augmented anastomotic urethroplasty: indications and outcome in 29 patients. J Urol 2001;165:1496–501.Abouassaly R, Angelmeier KW. Augmented anastomotic urethroplasty. J Urol 2007;177:2211–6.
Uretroplastia Anastomótica de Aumento
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Ventajas del injerto de mucosa oral vs piel con grosor completo
Fácil de cosechar
Obtención más segura
Mejor capacidad regenerativa del donante
Pocas complicaciones del sitio donador
Injerto Uretral
Markiewicz MR, Margarone III JE, Barbagli G, Scannapieco FA. Oral mucosa harvest: an overview of anatomic and biologic considerations. EAU-EBU Update Series 2007;5: 179–87.
Tipo de injerto
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Injerto Uretral
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Evitar sitio cercano a fosa tonsilar
Dejar 5 mm del margen gingival, ángulo bucal y conducto de Stensen
Hemostasia con diaterma bipolar
Cierre por 2ª intención
Markiewicz M, Lukose MA, Margarone JE, Barbagli G, Miller KS, Chuang S-K. The oral mucosal graft: a systematic review. J Urol 2007;78:387–94.
Injerto de mucosa oral
Injerto Uretral
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Alsikafi NF, Eisenberg M, McAninch JW (2005) Long-term outcomes of penile skin graft versus buccal mucosal graft for substitution urethroplasty of the anterior urethra. J Urol 173:87
Injerto Uretral
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Ventajas dorsal vs ventral
Tasa de estrechez a largo término 4% vs 14%
No se diverticuliza el parche
Estricturotomía
Kellner DS, Fracchia JA, Armenakas NA. Ventral onlay buccal mucosal grafts for anterior urethral strictures: long-term follow up. J Urol 2004;171:726–9.Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M. Bulbar urethroplasty using buccal mucosal grafts placed on the ventral, dorsal or lateral surface of the urethra: are results affected by the surgical technique? J Urol 2005;174:955–7.
Uretroplastia Substitutiva
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Estricturotomía dorsal + Uretroplastia por sustitución con parche de mucosa oral
Longitud ≥ 2 cm
Lumen uretral relativamente preservado
Espongiofibrosis 1-2mm circunferencial
Tasa de éxito 90%
Uretroplastia Substitutiva
Procedimiento de Barbagli
Barbagli G, Selli C, diCello V, Mottola A. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. Br J Urol 1996;78:929–32.Andrich DE, Leach CJ, Mundy AR. The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra. BJU Int 2001;88:385–9.
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Procedimiento de Barbagli
Uretroplastia Substitutiva
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tral Procedimiento de Orandi
Uretroplastia Substitutiva
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Uretroplastia Substitutiva
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Barbagli G, Palminteri E, Guazzoni G, Turini D, Lazzeri M (2006) Anastomotic fibrous rings as cause of stricture recurrence after bulbar onlay graft urethroplasty: an open issue. J Urol 175:104
Uretroplastia Substitutiva
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Uretroplastia Revisional
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Uretroplastia Escalonada
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Procedimiento de Swinney - Johansen
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Procedimiento de Swinney - Johansen
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Kröpft, D. Verweyen A. Indications and Limits for the use of Buccal Mucosa for Urethral Reconstruction. In: Schreiter F, Jordan GH (eds). Reconstructive Urethral Surgery. Springer, Heidelberg, 2006; 196-202
Procedimiento de Schreiter
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B. Breyer, J. McAninch et al. Multivariate Analysis of Risk Factors for Long-Term Urethroplasty Outcome. The Journal of Urology Vol. 183, 613-617, February 2010.
Uretroplastia
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B. Breyer, J. McAninch et al. Multivariate Analysis of Risk Factors for Long-Term Urethroplasty Outcome. The Journal of Urology Vol. 183, 613-617, February 2010.
Uretroplastia
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tral Morbilidad – Costos
Técnica quirúrgica depende del paciente y tipo de estrechez
Conclusiones
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¡ Gracias !