Every doctor has 3 roles in life: (1) teaching, (2) service to society, and (3) research and innovation. Steve Jobs stated, “Innovation distinguishes between a leader and a follower.” Invention is an art. If everyone follows the guidelines, who will invent?

How to Invent?

You need to understand and agree that there is a problem, and find out what are the various solutions to the problem. You need to ask yourself, what would you do if you were the patient? The answers that we have currently could be different when it comes to ourselves. And answering these questions leads to invention. To achieve something extraordinary, you have to work hard, extraordinarily. In my surgical practice, I was facing many challenges to which the answers I felt should have been different.

I would put forward a few inventions in my surgical practice.

Panurethral Strictures: Kulkarni Urethroplasty

Panurethral strictures due to lichen sclerosus were treated with Johanson staged urethroplasty (Figure 1, A). The problem with a staged urethroplasty is in the second stage, it would involve skin becoming a part of the urethra. Lichen sclerosus is a disease of genital skin, and skin grafts or flaps should not be used for urethral reconstruction. I invented a surgery. Through a perennial incision, I invaginated the penis. I did 1-sided dissection of the bulbar and penile urethra. Using penile invagination, the entire interior urethra becomes a single unit. One-sided dissection makes it becomes a minimally invasive technique keeping the neurovascular supply on the right side intact. (Figure 1, B-D). After opening the urethra dorsally I perform a dorsal meatotomy. Two buccal grafts are harvested and inserted to do a panurethral stricture. Kulkarni urethroplasty is published in Hinman Atlas of Surgery. With a 2-team approach, the entire surgery takes about 90 minutes. We have published the world’s largest data on panurethral strictures in The Urologic Clinics of North America.

My zeal to do a panurethral stricture with a single incision led to this invention.¹

New Step in Nontransecting Bulbar Urethroplasty: Joshi Step

The bulbar urethra should be transected only for trauma. Nontransection bulbar urethroplasty is now the latest recommendation by all the guidelines for bulbar stricture. We need to take care of mucosa in obliterative or near obliterative bulbar strictures. Mundy et al described nontransecting bulbar urethroplasty in 2012.² Joshi et al described further a new step in nontransecting bulbar urethroplasty.³ It involves suturing the proximal dilated mucosa to the distal mucosa without having to transect the mucosa (Figure 2). It is a true nontransecting bulbar urethroplasty. It can be used for obliterative strictures up to 2 cm in length.³

Novel Composite Technique for Complex Penile Strictures

Buccal mucosa graft (BMG) staged urethroplasty was used for complex penile strictures. In high-volume centers more than 39% of patients underwent graft contracture after the first stage. This required insertion of another graft, and a 2-stage surgery becomes a 3- and 4-stage surgery. We invented and innovated. For complex penile strictures due to failed hypospadias or multiple fistula, we lay open the urethra in stage 1 Johanson’s. We do not insert BMG in the first stage. After 6 months the patient is assessed, and a midline incision is made in the urethral plate and a BMG inserted as dorsal inlay. The urethra is tubularized in the same stage (Figure 3). The advantage is BMG remains moist and there is no risk of undergoing contracture. We have demonstrated a high success rate using our composite technique for complex panel strictures.⁴

Prostatic Capsule Flap for Urethra Perineal Fistula

Occasionally surgery for cancer of the rectum (excision) causes a urethra (prostate) perennial fistula. I invented a surgery using prostatic capsule flap for such patients. In a prone position an incision is made to demonstrate the fistula, which arises from the wall of the prostate. An inverted U-shaped incision is made on the prostate capsule and the flap is used to close the prostate perineal fistula (Figure 4, A and B). This is a simple surgery for a complex problem.

Think out of the box, invent. Invention will take you academically further. Complex problems may have simple solutions. If we all follow guidelines, who will invent?