The "Mini-Kulkarni": A Promising New Technique for the Treatment of Strictures of the Fossa Navicularis and Urethral Meatus

The "Mini-Kulkarni": A Promising New Technique for the Treatment of Strictures of the Fossa Navicularis and Urethral Meatus | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The "Mini-Kulkarni": A Promising New Technique for the Treatment of Strictures of the Fossa Navicularis and Urethral Meatus Diego Estevam Gomes Oliveira, Julio José Geminiani, Ricardo Gonçalves Alvim, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6805479/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To present the "Mini-Kulkarni" technique, a modification of the established Kulkarni approach for the management of urethral meatus and fossa navicularis strictures, and to demonstrate that glans preservation provides important patient benefits. Methods Six patients with urethral stricture in the urethral meatus and navicular fossa, limited to 5 cm of the distal penile urethra, confirmed by urethrocystography, were treated with the Mini-Kulkarni technique. This approach involves a longitudinal incision in the distal third of the penile shaft over the prepuce while preserving the glans, lateral rotation of the distal urethra, and placement of a jugal mucosa graft. Follow-up included uroflowmetry and patient-reported outcomes. Results All patients demonstrated improved urinary flow post-surgery. The mean maximum flow rate increased from 7.8 ml/s preoperatively to 15.2 ml/s at 6 months follow-up in the patients with available data. Complications included urinary spray in one patient and recurrence of stricture in another, with no cases of fistula formation or glans dehiscence. Conclusion The Mini-Kulkarni technique represents a promising approach for the treatment of navicular fossa and urethral meatus strictures. This technique offers a less invasive alternative compared to conventional approaches, preserving the glans and potentially reducing postoperative complications. Preliminary results indicate patient satisfaction after six months of follow-up. Further studies with longer follow-up periods and more comprehensive evaluation protocols are needed to validate the long-term efficacy and safety of this technique. Urethral stricture navicular fossa urethral meatus urethroplasty buccal mucosa graft surgical technique Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction The management of meatus and fossa navicularis strictures always are a challenge for reconstructive urologists. Navicular fossa stenosis accounts for approximately 18% of all urethral strictures [1]. Strictures involving the fossa navicularis and the meatus are more common in adult men and generally result from inflammatory (33–47%) and iatrogenic (33–37%) cause [2], with an average length of about 2.6 cm [1]. The management of strictures in these segments sometimes requires a different approach due to the difficulty of diagnosis and treatment. Patients with distal urethral narrowing often undergo aggressive procedures to treat a degree of urethral disease that is not compatible with the proposed technique. The therapeutic armamentarium for the treatment of distal urethral stricture is extensive, but often ineffective (e.g. repeated dilations) or associated with the risk of complications such as glans dehiscence or glandar fistula. Other techniques would be done without open the glans, accessing urethra dorsally or ventrally. We present a dorsolateral approach, as suggested by Kulkarni [3]. The purpose of this article is to present a variation of an established surgical technique [3] and to demonstrate that glans preservation provides important patient benefits. Methods This project adheres to the principles of the Declaration of Helsinki and Resolution CNS 466/12 of Brazil's National Health Council. The project was reviewed and approved by the Research Ethics Committee of Felicio Rocho Hospital (protocol number 6.509.591) and received a Certificate of Submission for Ethical Review (protocol number 71447523.4.0000.5125) from the CEP/CONEP system (Research Ethics Committee/National Research Ethics Commission). This study has been funded by the Coordination for the Improvement of Higher Education Personnel (CAPES), a department of the Brazilian Ministry of Education (MEC). Six patients with urethral stricture, in the urethral meatus and navicular fossa, limited to 5 cm of the distal penile urethra, confirmed by urethrocystography (FIGURE 1 ). All patients signed an informed consent for surgery. Surgical Technique The "mini-Kulkarni" technique is described as follows: longitudinal incision in the distal third of the penile shaft, over the prepuce and preserving the glans. (FIGURE 2 ) Opening of the tunica dartos, medially, lateral to the urethra, this provides a flap to prevent urethral fistula. (FIGURE 3 ) Incision of Buck's fascia (opposite the opening of the tunica dartos) and lateral rotation of the distal urethra from the normal urethra to the glans. (FIGURE 4 ) Posterior incision of the urethra, opening it from the healthy area, calibrated with a 20Fr catheter, Benique number 40 or Bougie 7mm, to the urethral meatus, calibrated with Benique number 60 or Bougie 10mm. (FIGURE 5 ) Next, after confirmation of the area to be grafted, a jugal mucosa graft harvested from the patient is placed in the same surgical procedure. The graft is fixed at its distal and proximal ends with 5 − 0 polydioxanone suture and in the urethral bed with 5 − 0 polyglycolic acid suture. (FIGURE 6 ) Urethral tabularization is performed over a 20 Fr catheter and sutured with 4 − 0 polydioxanone suture. The 20 Fr catheter is then removed and replaced with a 14 Fr silicone Foley catheter. The opening in Buck's fascia is closed with a 4 − 0 polydioxanone suture. The tunica dartos and the preputial skin are sutured with 4 − 0 polydioxanone (FIGURE 7 ). At the end of the procedure, only a longitudinal incision on the penile raphe is identified. The dressing is applied with light compression and left in place for 48 hours. The patient is instructed to maintain the indwelling catheter without traction and stable at the waist for 21 days, at which time the catheter is removed. Results Case Series: In this series we treated 6 patients with this technique (Table 1 ). All of them were operated by the main author. Table 1 Population: CASE AGE RACE CAUSE OF STRICTURE PREVIOUS TREATMENT? COMORBITY 1 25 BLACK LIQUEN DILATATION, MEATOPLASTY NO 2 38 BROWN LIQUEN DILATATION, MEATOPLASTY NO 3 48 WHITE IATROGENIC MEATOPLASTY NO 4 54 WHITE IDIOPATIC MEATOPLASTY NO 5 31 WHITE LIQUEN DILATATION, MEATOPLASTY NO 6 24 WHITE LIQUEN DILATATION NO After 30 days of surgery, all patients were inquired about the results. Since May, 2024 we are using USS-PROM validated to Portuguese [4,5]. All had improvement on streaming, but we only have objective data of 4/6 patients using Uroflowmetry to evaluate this. The complications noted were urinary spray (2/6) and recurrence of the stricture (1/6), with no fistula (Table 2 ). Table 2 – Results: CASE UROFLUX BEFORE PROCEDURE (ml/s) UROFLUX 01 MONTH AFTER PROCEDURE (ml/s) UROFLUX 06 MONTHS AFTER REMOVAL OF CATHETER (ml/s) SPRAY? 1 10 31 12 NO 2 5 12 7 NO 3 9 22 23 NO 4 * 10 14 NO 5 8 * 20 YES 6 7 * * NO * - No data available, patient 4 was obstructed previously the surgery. Lost contact with patient 6. Discussion Urethral stenosis is a challenge in urology, with 18% of cases located in the meatus and fossa navicularis [1]. The main causes include lichen sclerosus and iatrogenic factors [6]. Reconstructive urology is looking for effective and less invasive surgical techniques to treat strictures and preserve penile anatomy and function. The Mini-Kulkarni technique, adapted from the Kulkarni approach [3], has emerged as an alternative for the treatment of distal urethral strictures. This approach offers less surgical aggression compared to other techniques [6–8], preserving the glans. This feature is relevant, considering that complications such as glans dehiscence and distal urethral fistulas are concerns in conventional procedures. It is known that other techniques could preserve glans, like transmeatal approach [9], but if the stricture is more proximal then previously availed, this technique would become more difficult to perform. The adaptation of the Kulkarni technique, originally for long stenoses of the penile urethra or pan urethral strictures, demonstrates versatility in the field of urethroplasty. The dorsolateral approach and the use of a jugal mucosa graft in urethral reconstruction aim to reduce complications such as increased urethral detachment and possible penile curvature. Although there is no technique defined as the “gold standard” for the treatment of navicular fossa and urethral meatus stenosis, the Mini-Kulkarni approach looks promising. Preliminary results indicate patient satisfaction after six months of follow-up, suggesting benefits in efficacy and postoperative quality of life. The Mini-Kulkarni technique differs from traditional approaches, such as internal urethrotomy and dilation, in that it is less invasive and focuses on the aesthetic and functional preservation of the penis. The literature recognizes urethroplasty as the definitive treatment for stenosis, and the Mini-Kulkarni technique is in line with this practice, using buccal mucosa grafts, an approach with proven results. The current study has limitations, such as the small number of participants and the short follow-up period. To validate the efficacy and safety of the Mini-Kulkarni technique, further studies with stricter protocols and longer follow-up periods are needed. The ongoing study will implement a comprehensive evaluation protocol, including the Urethral Stricture Surgery Patient-Reported Outcome Measures (USS-PROM) validated for Portuguese [4,5], uroflowmetry, urethrocystography and urinary ultrasound. This methodological approach will allow for a more detailed analysis of long-term results. The Mini-Kulkarni technique represents a potential breakthrough in the treatment of navicular fossa and urethral meatus stenosis. Its innovative approach, focused on preserving the glans and minimizing post-operative complications, positions it as a promising option in the modern urological therapeutic arsenal. Although further studies are needed, preliminary results suggest that this technique can offer an optimized balance between surgical efficacy and patient quality of life, responding to a critical need in contemporary urological practice. Conclusion Passed 6 months of follow-up, we still have a high degree of satisfaction, but we still have a lack of objective data. The objective of this paper is to present a novel approach to strictures of the meatus and fossa navicularis. A new study has been conducted to get a better analysis of this technique. We expect a significant improvement in all parameters compared to the previous tests: quality of life, post-micturition volume, maximum flow and improvement of the urethral lumen. Declarations -Ethics approval and consent to participate: This project adheres to the principles of the Declaration of Helsinki and Resolution CNS 466/12 of Brazil's National Health Council. The project was reviewed and approved by the Research Ethics Committee of Felicio Rocho Hospital (protocol number 6.509.591) and received a Certificate of Submission for Ethical Review (protocol number 71447523.4.0000.5125) from the CEP/CONEP system (Research Ethics Committee/National Research Ethics Commission). This study has been funded by the Coordination for the Improvement of Higher Education Personnel (CAPES), a department of the Brazilian Ministry of Education (MEC). INFORMED CONSENT FORM FOR RESEARCH You are being invited to participate, as a volunteer, in the study/research titled Modified Kulkarni urethroplasty access for the treatment of meatal and navicular fossa stenosis, or "mini-Kulkarni" , conducted by Urologist XXXXXXXXXXXXXXX, under the supervision of Prof. Dr. XXXXXXXXX, within the Postgraduate Program of the Department of XXXXXXXXXXX. This study aims to evaluate the quality of life and surgical success rate of patients undergoing urethroplasty for distal urethral strictures, especially those within 5cm of the urethral meatus. If you agree to participate, your participation in this research will consist of undergoing the surgical treatment proposed in this research and explained by your Urologist in the office. A small fragment of mucosa will be removed from your mouth, from the inner lining of your cheek. Pre- and post-operative exams will be requested to evaluate your response to the treatment. Additionally, you will answer a questionnaire administered at XXXXXXXXXXXXXXX office on a date to be arranged. The questionnaires will be explained and administered by XXXXXXXXXXXXXXX and, eventually, an undergraduate research student from XXXXXXXXXXXXXXX, after prior training. In addition to this questionnaire, you will have scheduled follow-up appointments and must bring the follow-up exams requested at these appointments. Patients included in the study will undergo the technique described as "mini-Kulkarni," explained to you by Urologist XXXXXXXXXXXXXXX. This technical variation aims to reduce the risks of fistulas ("holes") between the urethra and the skin (as coverage is performed with several layers of tissue from the surgical area, covering the main suture line in the urethra) and to preserve glandular tissue, preventing fistulas or dehiscence at the site, as there is no ventral opening of the glans, as described in other techniques for correcting meatal and navicular fossa strictures. You may experience some discomfort, mainly related to difficulty chewing, bleeding in the mouth, and pain in the surgical wounds in the mouth and penis. The expected benefits from this research are to be able to describe a less aggressive technique for reconstructing the most distal part of the urethra, without needing to open the glans penis ("head of the penis"). You may not always be directly benefited by the research results, but you can contribute to scientific advancement. This research will help us identify the impact on quality of life and surgical outcomes of patients undergoing urethroplasties for distal urethral strictures in our service and others, aiming to improve the technique and post-operative care. The risks involve accidental disclosure of personal data; complications inherent to any urethroplasty may also occur: Technical complications or difficulties during surgery that prevent its completion or require the procedure to demand more than one surgery. Pain or discomfort in the penis, scrotum, and/or perineal region requiring analgesic medications. Presence of suture dehiscence, skin, flap, or graft necrosis, edema, and/or hematomas of the penis and/or scrotum, requiring clinical or surgical treatment. Possibility of infection in the urethra and bladder, requiring future treatment. Future possibility of new stricture, fistula formation, or urethral diverticulum, requiring new treatment. Suspension of the surgical procedure due to the impossibility of performing any type of anesthesia due to technical or clinical conditions arising immediately before the surgical act. Possibility of remaining with a catheter in the abdomen (cystostomy) for urine drainage for a few days. Possibility of scars with keloid formation (hypertrophic-coarse scar). Motor and/or sensory changes in the lower limbs due to positioning during surgery. Possibility of developing ventral penile curvature or perception of penile shortening after surgery. Possibility of urinary incontinence or erectile dysfunction after surgery. In some surgeries, it may be necessary to use oral mucosa: inner cheek, lips, or the region under the tongue for urethral reconstruction. In these cases, mouth edema, bleeding, temporary dietary restriction, and altered local sensation may occur. In some surgeries, it may be necessary to use skin from the penis or scrotum to reconstruct the urethra, which may lead to changes in penile sensitivity, post-operative edema and hematoma, and even deformities in penile shape. Your participation is not mandatory. At any time, you may decide to withdraw from participation and revoke your consent. Your refusal, withdrawal, or revocation of consent will not result in any prejudice to you or your treatment. If you choose not to participate in this study, you may opt for the described technique or others, such as a two-stage urethral surgery, graft implantation with glans opening, among others described and informed by your urologist (XXXXXXXXXXXXXXX). If you are over 18 years old and were treated and followed up by the Urology service at Hospital Felício Rocho between 2023 and 2025, having undergone the urethroplasty procedure described as "mini-Kulkarni," you will be included in the study. Prior to surgery, you must undergo a Kidney and Urinary Tract Ultrasound with post-void residual volume, free uroflowmetry, voiding cystourethrography, and retrograde urethrography. This data will be evaluated for your inclusion in the study. The data obtained through this research will be confidential and will not be disclosed, except in academic circles, to ensure the secrecy of your participation. At no time will your personal data be passed on by the researcher to third parties. The responsible researcher undertakes to make the consolidated results public in academic and scientific circles without any identification of participating individuals. The expenses necessary for conducting the research (statistical data analysis, publication, image collection costs) will NOT be charged, and you will not receive any monetary payment for your participation. You are assured that problems such as surgical complications like obstruction of the urine collection catheter, intense mouth bleeding, etc., arising from the study, will be treated at Hospital XXXXXXXXXXXXXXX. If you agree to participate in this research, please sign at the end of this document, which has two copies, one for you and the other for the responsible researcher. The patient will not bear any extra costs to undergo the procedure. All requested exams are part of the standard post-operative follow-up for urethral surgery (uroflowmetry, urinary tract ultrasound – with post-void residual assessment, and retrograde and voiding cystourethrography); furthermore, all are covered by both health insurance plans (mandatory coverage within the ANS List of Procedures) and by the SUS (Unified Health System). If the patient cannot find means to perform the exams or if these incur costs, these expenses will be covered by the Doctoral Scholarship received by the study's author. If you have any questions regarding the ethical aspect of this research, you may contact the Research Ethics Committee of Hospital Felício Rocho, which approved the conduct of this research, at the address and telephone number below: Address: XXXXXXXXXXXXXXX – Telephone: XXXXXXXXXXXXXXX If you have any questions regarding this research, you may contact the responsible physician: Responsible Researcher: XXXXXXXXXXXXXXX Supervisor: Prof. Dr. XXXXXXXXXXXXXXX Address: XXXXXXXXXXXXXXX ZIP Code: XXXXXXXXXXXXXXX Contact Telephone: XXXXXXXXXXXXXXX Informed Consent: I, ___________________________________________________________, declare that I have understood the objectives, risks, and benefits of my participation in the research, have had my questions answered by the responsible researcher, and agree to participate in the research. Thus, I sign this last page of this Consent Form and initial the preceding pages, together with the Urologist researcher XXXXXXXXXXXXXXX. XXXXXXXXXXXXXXX, ______ of ______________________ , 202 . Participant's Signature: ________________________________ Date: Researcher's Signature: ________________________________ Date: Consent for publication: Consent to publish and consent of images declarations are not applicable due to regulatory guidelines. Issued by Resolution No. 466, dated December 12, 2012, and Resolution 510/2016, both from the Brazilian National Health Council/Ministry of Health, as well as their complementary resolutions. We commit to: preserving the privacy of research participants whose data will be collected and ensuring that the information will be used solely for executing the project in question, as guaranteed by the Free and Informed Consent Form provided when the individual agrees to participate in the study. Funding This study has been funded by the Coordination for the Improvement of Higher Education Personnel (CAPES), a department of the Brazilian Ministry of Education (MEC). Process number: 88887.752371/2022-00 References Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral strictures: etiology and characteristics. Urology. 2005 Jun;65(6):1055-8. doi: 10.1016/j.urology.2004.12.018. Elliot S, Brandes SB. (2014) Etiology, histology, and classification of urethral stricture disease. In: Brandes SB, Morey AF (ed). Advanced Male Urethral and Genital Reconstructive Surgery, 2nd edn. Elsevier, Philadelphia, pp. 95-102. Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided anterior urethroplasty: a new dorsal onlay graft technique. BJU Int. 2009 Oct;104(8):1150-5. doi: 10.1111/j.1464-410X.2009.08590.x. Jorge KB, Viana GS, Jost RT, Rabolini EB, de Oliveira RT, Gorgen ARH, Tavares PM, Rosito TE. Brazilian portuguese validation of the patient-reported outcome measure for urethral stricture surgery (USS-PROM) questionnaire. Int Braz J Urol. 2024 May-Jun;50(3):261-276. doi: 10.1590/S1677-5538.IBJU.2023.0602. França WA, Barbosa OJP, Renato P, et al. Validation of the urethral stricture surgery patient-reported outcome measure (uss-prom) questionnaire into Brazilian Portuguese. MOJ Clin Med Case Rep . 2024;14(4):93-99. doi: 10.15406/mojcr.2024.14.00471 Armenakas NA, Morey AF, McAninch JW. Reconstruction of resistant strictures of the fossa navicularis and meatus. J Urol. 1998 Aug;160(2):359-63. Hoare D, Fersovich JH, Saavedra A, Rourke KF. Single-Stage Reconstruction of Fossa Navicularis Strictures Using a "Sliding-T" Dorsal Inlay Urethroplasty With Buccal Mucosal Graft. Urology. 2021 Jun;152:201-202. doi: 10.1016/j.urology.2020.12.031. Bracka A. A versatile two-stage hypospadias repair. Br J Plast Surg. 1995 Sep;48(6):345-52. doi: 10.1016/s0007-1226(95)90023-3. Nikolavsky D, Abouelleil M, Daneshvar M. Transurethral ventral buccal mucosa graft inlay urethroplasty for reconstruction of fossa navicularis and distal urethral strictures: surgical technique and preliminary results. Int Urol Nephrol. 2016 Nov;48(11):1823-1829. doi: 10.1007/s11255-016-1381-1. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6805479","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471398774,"identity":"80c46fbf-6606-4401-80ef-5879c914193d","order_by":0,"name":"Diego Estevam Gomes 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graft\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6805479/v1/eef19e36c825e1b38e91d968.jpeg"},{"id":84812021,"identity":"0dbe4f29-f3d9-44ea-9e69-861175090cce","added_by":"auto","created_at":"2025-06-17 14:56:58","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":33042,"visible":true,"origin":"","legend":"\u003cp\u003eFinal aspect\u003c/p\u003e","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6805479/v1/db25605886648d0859639e26.jpeg"},{"id":86890371,"identity":"f06be230-c9c0-448e-bcd0-41263ca8c257","added_by":"auto","created_at":"2025-07-16 19:46:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1560507,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6805479/v1/0cbed37b-8ca1-4b28-ab9f-8875fdcd4836.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The \"Mini-Kulkarni\": A Promising New Technique for the Treatment of Strictures of the Fossa Navicularis and Urethral Meatus","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe management of meatus and fossa navicularis strictures always are a challenge for reconstructive urologists. Navicular fossa stenosis accounts for approximately 18% of all urethral strictures [1]. Strictures involving the fossa navicularis and the meatus are more common in adult men and generally result from inflammatory (33\u0026ndash;47%) and iatrogenic (33\u0026ndash;37%) cause [2], with an average length of about 2.6 cm [1]. The management of strictures in these segments sometimes requires a different approach due to the difficulty of diagnosis and treatment.\u003c/p\u003e \u003cp\u003ePatients with distal urethral narrowing often undergo aggressive procedures to treat a degree of urethral disease that is not compatible with the proposed technique.\u003c/p\u003e \u003cp\u003eThe therapeutic armamentarium for the treatment of distal urethral stricture is extensive, but often ineffective (e.g. repeated dilations) or associated with the risk of complications such as glans dehiscence or glandar fistula. Other techniques would be done without open the glans, accessing urethra dorsally or ventrally. We present a dorsolateral approach, as suggested by Kulkarni [3]. The purpose of this article is to present a variation of an established surgical technique [3] and to demonstrate that glans preservation provides important patient benefits.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis project adheres to the principles of the Declaration of Helsinki and Resolution CNS 466/12 of Brazil\u0026apos;s National Health Council. The project was reviewed and approved by the Research Ethics Committee of Felicio Rocho Hospital (protocol number 6.509.591) and received a Certificate of Submission for Ethical Review (protocol number 71447523.4.0000.5125) from the CEP/CONEP system (Research Ethics Committee/National Research Ethics Commission).\u003c/p\u003e\n\u003cp\u003eThis study has been funded by the Coordination for the Improvement of Higher Education Personnel (CAPES), a department of the Brazilian Ministry of Education (MEC).\u003c/p\u003e\n\u003cp\u003eSix patients with urethral stricture, in the urethral meatus and navicular fossa, limited to 5 cm of the distal penile urethra, confirmed by urethrocystography (FIGURE \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). All patients signed an informed consent for surgery.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eSurgical Technique\u003c/h2\u003e\n \u003cp\u003eThe \u0026quot;mini-Kulkarni\u0026quot; technique is described as follows: longitudinal incision in the distal third of the penile shaft, over the prepuce and preserving the glans. (FIGURE \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) Opening of the tunica dartos, medially, lateral to the urethra, this provides a flap to prevent urethral fistula. (FIGURE \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) Incision of Buck\u0026apos;s fascia (opposite the opening of the tunica dartos) and lateral rotation of the distal urethra from the normal urethra to the glans. (FIGURE \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) Posterior incision of the urethra, opening it from the healthy area, calibrated with a 20Fr catheter, Benique number 40 or Bougie 7mm, to the urethral meatus, calibrated with Benique number 60 or Bougie 10mm. (FIGURE \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e) Next, after confirmation of the area to be grafted, a jugal mucosa graft harvested from the patient is placed in the same surgical procedure. The graft is fixed at its distal and proximal ends with 5\u0026thinsp;\u0026minus;\u0026thinsp;0 polydioxanone suture and in the urethral bed with 5\u0026thinsp;\u0026minus;\u0026thinsp;0 polyglycolic acid suture. (FIGURE \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e) Urethral tabularization is performed over a 20 Fr catheter and sutured with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polydioxanone suture. The 20 Fr catheter is then removed and replaced with a 14 Fr silicone Foley catheter. The opening in Buck\u0026apos;s fascia is closed with a 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polydioxanone suture. The tunica dartos and the preputial skin are sutured with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polydioxanone (FIGURE \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eAt the end of the procedure, only a longitudinal incision on the penile raphe is identified. The dressing is applied with light compression and left in place for 48 hours. The patient is instructed to maintain the indwelling catheter without traction and stable at the waist for 21 days, at which time the catheter is removed.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eCase Series:\u003c/h2\u003e \u003cp\u003eIn this series we treated 6 patients with this technique (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All of them were operated by the main author.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePopulation:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCASE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAGE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRACE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCAUSE OF STRICTURE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePREVIOUS TREATMENT?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCOMORBITY\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBLACK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIQUEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDILATATION, MEATOPLASTY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBROWN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIQUEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDILATATION, MEATOPLASTY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWHITE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIATROGENIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMEATOPLASTY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWHITE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIDIOPATIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMEATOPLASTY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWHITE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIQUEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDILATATION, MEATOPLASTY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWHITE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIQUEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDILATATION\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter 30 days of surgery, all patients were inquired about the results. Since May, 2024 we are using USS-PROM validated to Portuguese [4,5]. All had improvement on streaming, but we only have objective data of 4/6 patients using Uroflowmetry to evaluate this.\u003c/p\u003e \u003cp\u003eThe complications noted were urinary spray (2/6) and recurrence of the stricture (1/6), with no fistula (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Results:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCASE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUROFLUX BEFORE PROCEDURE (ml/s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUROFLUX 01 MONTH AFTER PROCEDURE (ml/s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUROFLUX 06 MONTHS AFTER REMOVAL OF CATHETER (ml/s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSPRAY?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYES\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* - No data available, patient 4 was obstructed previously the surgery. Lost contact with patient 6.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eUrethral stenosis is a challenge in urology, with 18% of cases located in the meatus and fossa navicularis [1]. The main causes include lichen sclerosus and iatrogenic factors [6]. Reconstructive urology is looking for effective and less invasive surgical techniques to treat strictures and preserve penile anatomy and function.\u003c/p\u003e \u003cp\u003eThe Mini-Kulkarni technique, adapted from the Kulkarni approach [3], has emerged as an alternative for the treatment of distal urethral strictures. This approach offers less surgical aggression compared to other techniques [6\u0026ndash;8], preserving the glans. This feature is relevant, considering that complications such as glans dehiscence and distal urethral fistulas are concerns in conventional procedures. It is known that other techniques could preserve glans, like transmeatal approach [9], but if the stricture is more proximal then previously availed, this technique would become more difficult to perform.\u003c/p\u003e \u003cp\u003eThe adaptation of the Kulkarni technique, originally for long stenoses of the penile urethra or pan urethral strictures, demonstrates versatility in the field of urethroplasty. The dorsolateral approach and the use of a jugal mucosa graft in urethral reconstruction aim to reduce complications such as increased urethral detachment and possible penile curvature.\u003c/p\u003e \u003cp\u003eAlthough there is no technique defined as the \u0026ldquo;gold standard\u0026rdquo; for the treatment of navicular fossa and urethral meatus stenosis, the Mini-Kulkarni approach looks promising. Preliminary results indicate patient satisfaction after six months of follow-up, suggesting benefits in efficacy and postoperative quality of life.\u003c/p\u003e \u003cp\u003eThe Mini-Kulkarni technique differs from traditional approaches, such as internal urethrotomy and dilation, in that it is less invasive and focuses on the aesthetic and functional preservation of the penis. The literature recognizes urethroplasty as the definitive treatment for stenosis, and the Mini-Kulkarni technique is in line with this practice, using buccal mucosa grafts, an approach with proven results.\u003c/p\u003e \u003cp\u003eThe current study has limitations, such as the small number of participants and the short follow-up period. To validate the efficacy and safety of the Mini-Kulkarni technique, further studies with stricter protocols and longer follow-up periods are needed.\u003c/p\u003e \u003cp\u003eThe ongoing study will implement a comprehensive evaluation protocol, including the Urethral Stricture Surgery Patient-Reported Outcome Measures (USS-PROM) validated for Portuguese [4,5], uroflowmetry, urethrocystography and urinary ultrasound. This methodological approach will allow for a more detailed analysis of long-term results.\u003c/p\u003e \u003cp\u003eThe Mini-Kulkarni technique represents a potential breakthrough in the treatment of navicular fossa and urethral meatus stenosis. Its innovative approach, focused on preserving the glans and minimizing post-operative complications, positions it as a promising option in the modern urological therapeutic arsenal. Although further studies are needed, preliminary results suggest that this technique can offer an optimized balance between surgical efficacy and patient quality of life, responding to a critical need in contemporary urological practice.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePassed 6 months of follow-up, we still have a high degree of satisfaction, but we still have a lack of objective data. The objective of this paper is to present a novel approach to strictures of the meatus and fossa navicularis. A new study has been conducted to get a better analysis of this technique. We expect a significant improvement in all parameters compared to the previous tests: quality of life, post-micturition volume, maximum flow and improvement of the urethral lumen.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e-Ethics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project adheres to the principles of the Declaration of Helsinki and Resolution CNS 466/12 of Brazil's National Health Council. The project was reviewed and approved by the Research Ethics Committee of Felicio Rocho Hospital (protocol number 6.509.591) and received a Certificate of Submission for Ethical Review (protocol number 71447523.4.0000.5125) from the CEP/CONEP system (Research Ethics Committee/National Research Ethics Commission).\u003c/p\u003e\n\u003cp\u003eThis study has been funded by the Coordination for the Improvement of Higher Education Personnel (CAPES), a department of the Brazilian Ministry of Education (MEC).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eINFORMED CONSENT FORM FOR RESEARCH\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYou are being invited to participate, as a volunteer, in the study/research titled \u003cstrong\u003eModified Kulkarni urethroplasty access for the treatment of meatal and navicular fossa stenosis, or \"mini-Kulkarni\"\u003c/strong\u003e, conducted by Urologist XXXXXXXXXXXXXXX, under the supervision of Prof. Dr. XXXXXXXXX, within the Postgraduate Program of the Department of XXXXXXXXXXX.\u003c/p\u003e\n\u003cp\u003eThis study aims to evaluate the quality of life and surgical success rate of patients undergoing urethroplasty for distal urethral strictures, especially those within 5cm of the urethral meatus.\u003c/p\u003e\n\u003cp\u003eIf you agree to participate, your participation in this research will consist of undergoing the surgical treatment proposed in this research and explained by your Urologist in the office. A small fragment of mucosa will be removed from your mouth, from the inner lining of your cheek. Pre- and post-operative exams will be requested to evaluate your response to the treatment. Additionally, you will answer a questionnaire administered at XXXXXXXXXXXXXXX office on a date to be arranged. The questionnaires will be explained and administered by XXXXXXXXXXXXXXX and, eventually, an undergraduate research student from XXXXXXXXXXXXXXX, after prior training. In addition to this questionnaire, you will have scheduled follow-up appointments and must bring the follow-up exams requested at these appointments.\u003c/p\u003e\n\u003cp\u003ePatients included in the study will undergo the technique described as \"mini-Kulkarni,\" explained to you by Urologist XXXXXXXXXXXXXXX. This technical variation aims to reduce the risks of fistulas (\"holes\") between the urethra and the skin (as coverage is performed with several layers of tissue from the surgical area, covering the main suture line in the urethra) and to preserve glandular tissue, preventing fistulas or dehiscence at the site, as there is no ventral opening of the glans, as described in other techniques for correcting meatal and navicular fossa strictures.\u003c/p\u003e\n\u003cp\u003eYou may experience some discomfort, mainly related to difficulty chewing, bleeding in the mouth, and pain in the surgical wounds in the mouth and penis.\u003c/p\u003e\n\u003cp\u003eThe expected benefits from this research are to be able to describe a less aggressive technique for reconstructing the most distal part of the urethra, without needing to open the glans penis (\"head of the penis\"). You may not always be directly benefited by the research results, but you can contribute to scientific advancement.\u003c/p\u003e\n\u003cp\u003eThis research will help us identify the impact on quality of life and surgical outcomes of patients undergoing urethroplasties for distal urethral strictures in our service and others, aiming to improve the technique and post-operative care. The risks involve accidental disclosure of personal data; complications inherent to any urethroplasty may also occur:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eTechnical complications or difficulties during surgery that prevent its completion or require the procedure to demand more than one surgery.\u003c/li\u003e\n \u003cli\u003ePain or discomfort in the penis, scrotum, and/or perineal region requiring analgesic medications.\u003c/li\u003e\n \u003cli\u003ePresence of suture dehiscence, skin, flap, or graft necrosis, edema, and/or hematomas of the penis and/or scrotum, requiring clinical or surgical treatment.\u003c/li\u003e\n \u003cli\u003ePossibility of infection in the urethra and bladder, requiring future treatment.\u003c/li\u003e\n \u003cli\u003eFuture possibility of new stricture, fistula formation, or urethral diverticulum, requiring new treatment.\u003c/li\u003e\n \u003cli\u003eSuspension of the surgical procedure due to the impossibility of performing any type of anesthesia due to technical or clinical conditions arising immediately before the surgical act.\u003c/li\u003e\n \u003cli\u003ePossibility of remaining with a catheter in the abdomen (cystostomy) for urine drainage for a few days.\u003c/li\u003e\n \u003cli\u003ePossibility of scars with keloid formation (hypertrophic-coarse scar).\u003c/li\u003e\n \u003cli\u003eMotor and/or sensory changes in the lower limbs due to positioning during surgery.\u003c/li\u003e\n \u003cli\u003ePossibility of developing ventral penile curvature or perception of penile shortening after surgery.\u003c/li\u003e\n \u003cli\u003ePossibility of urinary incontinence or erectile dysfunction after surgery.\u003c/li\u003e\n \u003cli\u003eIn some surgeries, it may be necessary to use oral mucosa: inner cheek, lips, or the region under the tongue for urethral reconstruction. In these cases, mouth edema, bleeding, temporary dietary restriction, and altered local sensation may occur.\u003c/li\u003e\n \u003cli\u003eIn some surgeries, it may be necessary to use skin from the penis or scrotum to reconstruct the urethra, which may lead to changes in penile sensitivity, post-operative edema and hematoma, and even deformities in penile shape.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eYour participation is not mandatory. At any time, you may decide to withdraw from participation and revoke your consent. Your refusal, withdrawal, or revocation of consent will not result in any prejudice to you or your treatment. If you choose not to participate in this study, you may opt for the described technique or others, such as a two-stage urethral surgery, graft implantation with glans opening, among others described and informed by your urologist (XXXXXXXXXXXXXXX).\u003c/p\u003e\n\u003cp\u003eIf you are over 18 years old and were treated and followed up by the Urology service at Hospital Felício Rocho between 2023 and 2025, having undergone the urethroplasty procedure described as \"mini-Kulkarni,\" you will be included in the study. Prior to surgery, you must undergo a Kidney and Urinary Tract Ultrasound with post-void residual volume, free uroflowmetry, voiding cystourethrography, and retrograde urethrography. This data will be evaluated for your inclusion in the study.\u003c/p\u003e\n\u003cp\u003eThe data obtained through this research will be confidential and will not be disclosed, except in academic circles, to ensure the secrecy of your participation. At no time will your personal data be passed on by the researcher to third parties. The responsible researcher undertakes to make the consolidated results public in academic and scientific circles without any identification of participating individuals.\u003c/p\u003e\n\u003cp\u003eThe expenses necessary for conducting the research (statistical data analysis, publication, image collection costs) will NOT be charged, and you will not receive any monetary payment for your participation.\u003c/p\u003e\n\u003cp\u003eYou are assured that problems such as surgical complications like obstruction of the urine collection catheter, intense mouth bleeding, etc., arising from the study, will be treated at Hospital XXXXXXXXXXXXXXX.\u003c/p\u003e\n\u003cp\u003eIf you agree to participate in this research, please sign at the end of this document, which has two copies, one for you and the other for the responsible researcher.\u003c/p\u003e\n\u003cp\u003eThe patient will not bear any extra costs to undergo the procedure. All requested exams are part of the standard post-operative follow-up for urethral surgery (uroflowmetry, urinary tract ultrasound – with post-void residual assessment, and retrograde and voiding cystourethrography); furthermore, all are covered by both health insurance plans (mandatory coverage within the ANS List of Procedures) and by the SUS (Unified Health System). If the patient cannot find means to perform the exams or if these incur costs, these expenses will be covered by the Doctoral Scholarship received by the study's author.\u003c/p\u003e\n\u003cp\u003eIf you have any questions regarding the ethical aspect of this research, you may contact the Research Ethics Committee of Hospital Felício Rocho, which approved the conduct of this research, at the address and telephone number below:\u003c/p\u003e\n\u003cp\u003eAddress: XXXXXXXXXXXXXXX – Telephone: XXXXXXXXXXXXXXX\u003c/p\u003e\n\u003cp\u003eIf you have any questions regarding this research, you may contact the responsible physician:\u003c/p\u003e\n\u003cp\u003eResponsible Researcher: XXXXXXXXXXXXXXX\u003c/p\u003e\n\u003cp\u003eSupervisor: Prof. Dr. XXXXXXXXXXXXXXX\u003c/p\u003e\n\u003cp\u003eAddress: XXXXXXXXXXXXXXX ZIP Code: XXXXXXXXXXXXXXX\u003c/p\u003e\n\u003cp\u003eContact Telephone: XXXXXXXXXXXXXXX\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI, ___________________________________________________________, declare that I have understood the objectives, risks, and benefits of my participation in the research, have had my questions answered by the responsible researcher, and agree to participate in the research. Thus, I sign this last page of this Consent Form and initial the preceding pages, together with the Urologist researcher XXXXXXXXXXXXXXX.\u003c/p\u003e\n\u003cp\u003eXXXXXXXXXXXXXXX, ______ of ______________________\u003cstrong\u003e, 202\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eParticipant's Signature: ________________________________\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDate:\u003c/p\u003e\n\u003cp\u003eResearcher's Signature: ________________________________\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to publish and consent of images declarations are not applicable due to regulatory guidelines.\u003c/p\u003e\n\u003cp\u003eIssued by Resolution No. 466, dated December 12, 2012, and Resolution 510/2016, both from the Brazilian National Health Council/Ministry of Health, as well as their complementary resolutions. We commit to: \u0026nbsp; preserving the privacy of research participants whose data will be collected and ensuring that the information will be used solely for executing the project in question, as guaranteed by the Free and Informed Consent Form provided when the individual agrees to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been funded by the Coordination for the Improvement of Higher Education Personnel (CAPES), a department of the Brazilian Ministry of Education (MEC). Process number: 88887.752371/2022-00\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral strictures: etiology and characteristics. Urology. 2005 Jun;65(6):1055-8. doi: 10.1016/j.urology.2004.12.018.\u003c/li\u003e\n\u003cli\u003eElliot S, Brandes SB. (2014) Etiology, histology, and classification of urethral stricture disease. In: Brandes SB, Morey AF (ed). Advanced Male Urethral and Genital Reconstructive Surgery, 2nd edn. Elsevier, Philadelphia, pp. 95-102.\u003c/li\u003e\n\u003cli\u003eKulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided anterior urethroplasty: a new dorsal onlay graft technique. BJU Int. 2009 Oct;104(8):1150-5. doi: 10.1111/j.1464-410X.2009.08590.x. \u003c/li\u003e\n\u003cli\u003eJorge KB, Viana GS, Jost RT, Rabolini EB, de Oliveira RT, Gorgen ARH, Tavares PM, Rosito TE. Brazilian portuguese validation of the patient-reported outcome measure for urethral stricture surgery (USS-PROM) questionnaire. Int Braz J Urol. 2024 May-Jun;50(3):261-276. doi: 10.1590/S1677-5538.IBJU.2023.0602. \u003c/li\u003e\n\u003cli\u003eFran\u0026ccedil;a WA, Barbosa OJP, Renato P, et al. Validation of the urethral stricture surgery patient-reported outcome measure (uss-prom) questionnaire into Brazilian Portuguese.\u003cem\u003e MOJ Clin Med Case Rep\u003c/em\u003e. 2024;14(4):93-99. doi: 10.15406/mojcr.2024.14.00471\u003c/li\u003e\n\u003cli\u003eArmenakas NA, Morey AF, McAninch JW. Reconstruction of resistant strictures of the fossa navicularis and meatus. J Urol. 1998 Aug;160(2):359-63.\u003c/li\u003e\n\u003cli\u003eHoare D, Fersovich JH, Saavedra A, Rourke KF. Single-Stage Reconstruction of Fossa Navicularis Strictures Using a \"Sliding-T\" Dorsal Inlay Urethroplasty With Buccal Mucosal Graft. Urology. 2021 Jun;152:201-202. doi: 10.1016/j.urology.2020.12.031. \u003c/li\u003e\n\u003cli\u003eBracka A. A versatile two-stage hypospadias repair. Br J Plast Surg. 1995 Sep;48(6):345-52. doi: 10.1016/s0007-1226(95)90023-3. \u003c/li\u003e\n\u003cli\u003eNikolavsky D, Abouelleil M, Daneshvar M. Transurethral ventral buccal mucosa graft inlay urethroplasty for reconstruction of fossa navicularis and distal urethral strictures: surgical technique and preliminary results. Int Urol Nephrol. 2016 Nov;48(11):1823-1829. doi: 10.1007/s11255-016-1381-1.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Urethral stricture, navicular fossa, urethral meatus, urethroplasty, buccal mucosa graft, surgical technique","lastPublishedDoi":"10.21203/rs.3.rs-6805479/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6805479/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo present the \"Mini-Kulkarni\" technique, a modification of the established Kulkarni approach for the management of urethral meatus and fossa navicularis strictures, and to demonstrate that glans preservation provides important patient benefits.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSix patients with urethral stricture in the urethral meatus and navicular fossa, limited to 5 cm of the distal penile urethra, confirmed by urethrocystography, were treated with the Mini-Kulkarni technique. This approach involves a longitudinal incision in the distal third of the penile shaft over the prepuce while preserving the glans, lateral rotation of the distal urethra, and placement of a jugal mucosa graft. Follow-up included uroflowmetry and patient-reported outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll patients demonstrated improved urinary flow post-surgery. The mean maximum flow rate increased from 7.8 ml/s preoperatively to 15.2 ml/s at 6 months follow-up in the patients with available data. Complications included urinary spray in one patient and recurrence of stricture in another, with no cases of fistula formation or glans dehiscence.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe Mini-Kulkarni technique represents a promising approach for the treatment of navicular fossa and urethral meatus strictures. This technique offers a less invasive alternative compared to conventional approaches, preserving the glans and potentially reducing postoperative complications. Preliminary results indicate patient satisfaction after six months of follow-up. Further studies with longer follow-up periods and more comprehensive evaluation protocols are needed to validate the long-term efficacy and safety of this technique.\u003c/p\u003e","manuscriptTitle":"The \"Mini-Kulkarni\": A Promising New Technique for the Treatment of Strictures of the Fossa Navicularis and Urethral Meatus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-17 14:56:53","doi":"10.21203/rs.3.rs-6805479/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"215690d3-f5dd-4699-850d-aa1353483ab4","owner":[],"postedDate":"June 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-16T19:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-17 14:56:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6805479","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6805479","identity":"rs-6805479","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}