|Year : 2010 | Volume
| Issue : 4 | Page : 605-606
Upper transverse scrotal approach for urethral stricture: A novel approach
Parag S Bhirud, Arun Chawla, Joseph Thomas
Department of Urology, Kasturba Medical College, Manipal, India
|Date of Web Publication||31-Dec-2010|
Parag S Bhirud
Department of Urology, Kasturba Medical College, Manipal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhirud PS, Chawla A, Thomas J. Upper transverse scrotal approach for urethral stricture: A novel approach. Indian J Urol 2010;26:605-6
Seitz M, Liedl B, Becker A, Gratzke C, Reich O, Stief C. Upper transverse scrotal approach for muscle- and nerve-sparing urethral stricture repair. World J Urol 2009;27:667-72.
The authors prospectively evaluated this new surgical approach for urethral strictures. Thirteen patients were operated by a new technique using an upper transverse scrotal incision. Patients with proximal bulbar strictures were excluded. Out of 13 patients, 8 underwent end-to-end anastomosis and 5 patients underwent free foreskin dorsal onlay graft. Among 13 patients, 3 had the history of previous transurethral procedures and 10 patients had unknown etiology.
The new approach included a transverse incision of about 3-4 cm at the penoscrotal junction in supine position with legs abducted. Dartos and Buck's fasciae were opened to approach the corpus spongiosum. Dissection of scrotal septum for exposure of proximal urethra or extension of incision in an inverted T fashion along the ventral midline of penis for the exposure of distal penile urethra was optional.
Postoperatively, catheter was removed after 20 days and MCU was obtained. There was no penile deformity or troublesome postvoid dribbling. No patient had newly developed erectile dysfunction after surgery. However, 7.7% patients had decreased force of ejaculation. Patients were followed up with uroflowmetry and PVR at 6 weeks, 6 months, and 12 months following surgery. Additionally, sexual function and postvoid dribbling were assessed by a nonstandardized questionnaire.
The authors concluded that upper transverse scrotal approach may improve functional outcomes in terms of sexual dysfunction and incontinence rates. 
| Comments|| |
The most common cause of urethral strictures remains unknown. Surgical treatment of stricture disease is a continuously evolving process and currently there is renewed controversy over the best methods of urethral reconstruction. Moreover, the superiority of one technique over another has not been clearly established.
Standard surgical approach to the bulbar urethra includes extensive dissection of bulbospongiosus muscle and sectioning of the central tendon of perineum for proximal bulbar strictures. Consequently, postvoid dribbling and semen sequestration are likely complications of any urethroplasty. This morbidity was found to be related to urethral sacculation as evident on postoperative voiding cystourethrography. 
Recently, Barbagli et al . performed a muscle and nerve sparing bulbar urethroplasty in 12 patients with different etiology. Result was comparable with present study at 6 and 12 months postoperatively. This novel technique again represents an attempt at reducing the above-mentioned complications. 
Dubey et al . studied 109 patients with different types of substitution urethroplasty for recurrent anterior urethral strictures. The rates of ejaculatory dysfunction, erectile dysfunction, and postvoid dribble were 2%, 3%, and 9%, respectively, with dorsal onlay grafting versus 14%, 7%, and 27% with ventral onlay.  A retrospective study of 153 patients by Barbagli et al . with mean follow up of 68 months showed a 23.3% ejaculatory dysfunction in patients 20-50 years old, without diabetes or vascular diseases and single perineal urethroplasty.  Present series shows no immediate ejaculatory dysfunction.
There has been a concern about the exact cause of postvoid dribbling and ejaculatory dysfunction. Possible hypotheses are the technique of cutting bulbocavernous muscle, traction over BCM or damage to muscle/nerve, while suturing during wound closure. 
With this technique, the authors have tried to preserve the BCM with successful preservation of the nervous and muscular structures involved in the mechanism of urination and ejaculation from the bulbar urethra, but longer follow-up on a larger series of patients is necessary to confirm satisfactory preliminary reports of this technique. Moreover, posterior and most proximal anterior urethral strictures cannot be approached by this technique.
| References|| |
|1.||Seitz M, Liedl B, Becker A, Gratzke C, Reich O, Stief C. Upper transverse scrotal approach for muscle- and nerve-sparing urethral stricture repair. World J Urol 2009;27:667-72. |
|2.||Barbagli G, Stefani SD, Annino F, Carne CD, Bianchi G. Muscle and Nerve-sparing Bulbar Urethroplasty: A New Technique. European Urology 2008;54:35-43. |
|3.||Dubey D, Kumar A, Bansal P, Srivastava A, Kapoor R, Mandhani A, et al. Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques. BJU Int 2003;91:215-8. |
|4.||Barbagli G, Angelis MD, Romano G, Lazzeri M. Long-Term Follow up of Bulbar End-to-End Anastomosis: A Retrospective Analysis of 153 Patients in a Single Center Experience. J Urol 2007;178:2470. |
|5.||Barbagli G. Neuroanatomy of the Male Urethra and Perineum. European Urology 2006;50:1367. |