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ORIGINAL ARTICLE
Year : 2001  |  Volume : 17  |  Issue : 2  |  Page : 145-151
 

Single stage reconstruction of complex anterior urethral strictures


Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Correspondence Address:
Anant Kumar
Department of Urology, SGPGIMS, Lucknow - 226 014
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Purpose: Single stage reconstruction of long, com­plex urethral strictures is technically demanding and may require the use of more than one tissue transfer technique. We describe our experience in the manage­ment of such strictures with a variety of urethroplasty techniques.
Materials and Methods: Between 1989 and 1999, 25 men (mean age 38.5 years) underwent single stage re­construction of panurethral, multiple segment or focally dense strictures [mean length 11.2 cm (range 8-17 cm)]. 8 patients had combined substitution urethroplasty with a circumpenile fasciocutaneous flap and a free graft of bladder/buccal mucosa or tunica vaginalis . flap. In 10 patients a single tissue transfer technique was used. 3 patients underwent an augmented roof/floor strip ure­throplasty with a penile skin flap. 4 patients with multi­ple segment strictures (separate pendulous and bulbar) underwent distal onlay flap and proximal anastomotic urethroplasty.
Results: The median ,follow-up was 46.5 months (range 6-88 months). The mean postoperative flow rate improved to 22.5 ml/sec. 2 patients developed fistulae requiring repair. Recurrent stricture developed in 5 (20.8%) patients, of which 2 were managed with visual internal urethrotomy, 2 with anastomotic urethroplasty and 1 with a two-stage procedure. Pseudodiverticulum and post-void dribbling were seen in 6 (25%) patients.
Conclusions: Successful outcome of single stage re­construction of long complex strictures can be achieved with a combination of various tissue transfer methods. The urologist who has a thorough knowledge of penile skin and urethral vascular anatomy and a wide array of substitution techniques in his armamentarium can un­dertake approach to such strictures.


Keywords: Urethroplasty; Penile Skin Flap; Buccal Mucosa


How to cite this article:
Dubey D, Srivastava A, Kapoor R, Kumar A, Bhandari M, Mandhani A. Single stage reconstruction of complex anterior urethral strictures. Indian J Urol 2001;17:145-51

How to cite this URL:
Dubey D, Srivastava A, Kapoor R, Kumar A, Bhandari M, Mandhani A. Single stage reconstruction of complex anterior urethral strictures. Indian J Urol [serial online] 2001 [cited 2021 Jan 28];17:145-51. Available from: https://www.indianjurol.com/text.asp?2001/17/2/145/21045



   Introduction Top


Strictures are termed complex when they have focally dense segments, are lengthy or multiple and/or have associated defi­ciency of penile skin. [1] These strictures pose problems in man­agement due to their length and associated spongiofibrosis and are usually an indication for a 2-staged scrotal inlay [2],[3] or a staged mesh graft urethroplasty. [4] Staged scrotal inlays are cumbersome for patients and associated with multiple revisions, [5] high recur­rence rates' and complications like diverticulum formation, hair growth and urethrocutaneous fistula. [7] Experience with mesh­graft urethroplasty is limited and patients may require increased number of interventions in the interim period. [8] Whenever pos­sible a single stage reconstruction is always preferable to pa­tients. With the excellent results of buccal mucosal graft urethroplasty there has been a renewed interest in the com­bined use of grafts and flaps for such complex strictures. [9],[10] In experienced hands a single stage procedure involving a combi­nation of different techniques can give good results. [10] We share our experience in the single stage reconstruction of complex lengthy strictures with various techniques.


   Patients and Methods Top


Between 1989 and 1999, 25 patients (mean age 38.5 years) underwent single stage substitution urethroplasty for compelx urethral strictures. Of these, 18 patients had panu­rethral strictures (defined as stricture involving significant portions of both pendulous and bulbar urethra) [1] with a mean length of 12.5 cm (range 12-14 cm), 4 had multiple segment strictures (2 separate strictures with intervening normal ure­thra), and 3 had long strictures with a focal area of almost destroyed urethral plate [Table - 1]. The aetiology was post inflammatory, [13] ischaemic (following urethral catheteriza­tion), [5] Balanitis xerotica obliterans, [3] and traumatic. [4] All pa­tients had a prior history of urethral intervention in the form of dilatations and/or visual internal urethrotomy. In addi­tion 3 patients had a failed anastomotic urethroplasty performed elsewhere. 11 patients had a suprapubic cystostomy and 14 patients had a mean peak flow rate of 7.4 ml/sec. All patients were evaluated with a retrograde urethrogram and micturating cystourethrogram.

Reconstruction Techniques

Panurethral strictures: When sufficient penile skin was available, a circular fasciocutaneous flap [11] was used as an onlay in strictures with a healthy salvageable urethral plate and as tube where the urethral plate was very thin or un­healthy. When penile skin was insufficient to substitute the entire stricture, a longitudinal penoscrotal-midline flap, [1] multiple buccal mucosal grafts or combined tissue transfer techniques were used. Combined tissue transfer was performed with a circular fasciocutaneous flap onlay on the pendulous urethra and a bladder/buccal mucosal graft or tunica vaginalis onlay flap for the bulbar urethra. Buccal and bladder mucosa were harvested using the tech­niques described by Morey and McAninch [12] and Keating et al [13] respectively. The flap/graft onlay was placed either ventrally or dorsally on the corporeal bodies.

Multiple segment strictures: When normal urethra in­tervened between 2 separate stricture segments, circular fasciocutaneous flap onlay was used for the distal (pen­dulous) stricture and an anastomotic urethroplasty for the proximal (bulbar) stricture.

Strictures with a focally dense urethral plate: These pa­tients underwent an augmented roof/floor strip anastomosis with flap onlay. The urethra was dissected off the corporeal bodies following which a ventral/dorsal urethrotomy was performed. A segment of abnormal/unhealthy urethral plate (max 2 cm) was excised and re-anastomosed with interrupted sutures. Subsequently a circular fasciocutaneous flap onlay was performed [Figure - 1]a and b.

Inferior pubectomy was performed to facilitate proxi­mal placement of the flap/graft/tube in patients with high bulbar strictures. Reconstruction of associated meatal stric­tures (as in BXO) was performed by glans wing creation and ventral flap onlay [14] or dorsal flap onlay. [15]

Patients were followed postoperatively with uroflow­metry, urethral calibration and retrograde urethrograms at 3 months and subsequently when required.


   Results Top


18 patients had panurethral strictures with a mean length of 12.5 cm (range 12-14 cm). Of these 10 patients had reconstruction with a single tissue transfer technique (cir­cular penile fasciocutaneous flap onlay [3] /tube, [4] midline penoscrotal longitudinal flap [2] and multiple buccal mucosa strips). [1] Combined tissue transfer techniques were used in 8 patients (penile flap + buccal mucosa, [4] penile flap + blad­der mucosa, [3] penile flap + tunica vaginalis flap). [1] 4 pa­tients had an augmented roof/floor strip urethroplasty for focally dense strictures and 3 patients had a distal (pendu­lous) flap onlay and proximal (bulbar) anastomotic ure­throplasty [Table - 2].

The median follow-up period was 46.5 months (range 6­88 months). The mean post-operative flow rate improved to 22.5 ml/sec (range 16-31 ml/sec). Excellent postopera­tive outcome was achieved in 20 patients [Figure - 2]a, b,[Figure - 3]a, b. 3 patients with circular fasciocutaneous flap onlay de­veloped superficial epidermal necrosis which settled on conservative management. Of the patients who had com­bined tissue transfer (flap and graft), 2 developed subcoronal fistulae which required closure. 5 patients developed stric­ture recurrence at a mean time of 22 months post-opera­tively. The patient who had a combination of a flap and tunica vaginalis graft developed a dense recurrent stricture (4cm) in the grafted (bulbar) segment. This patient under­went stage one of the staged scrotal inlay urethroplasty. He was happy with the outcome and refused second stage of the operation. I patient with a full circumference tube re­construction developed recurrence at the bulbomembranous region which required anastomotic urethroplasty. 3 patients (1 with a focally dense stricture and 2 with multiple seg­ment involvement) developed recurrences. Of these 2 were cured with visual internal urethrotomy whereas 1 patient (multiple segment stricture) required a repeat anastomotic urethroplasty for the bulbar stricture. 1 patient who had a midline longitudinal penoscrotal flap onlay developed in­traluminal hair growth in the scrotal segment. Pseudo-di­verticulum formation was seen in 6 patients (1 with bladder mucosa, 4 patients with a cirumpenile flap and I patient with a longitudinal penoscrotal flap) [Table - 2]. Post-void dribbling was a troublesome complication in 6 patients. None of the patients reported erectile dysfunction.


   Discussion Top


Our results demonstrate that excellent outcome of sin­gle stage reconstruction for complex urethral strictures can be achieved with the appropriate use of various urethro­plasty techniques. A 20% recurrence rate after a median follow-up of 46.5 months could be acceptable in patients who have had multiple previous operations. In our expe­rience the circumpenile fasciocutaneous flap has emerged as the most versatile technique of tissue transfer for long strictures. It is hairless and can provide length up to 15 cm [Figure - 4] in some patients (as was seen in 3 of our patients). It can be transferred to any part of the urethra right from the meatus till the bladder neck. Inferior pubectomy is a useful adjunct in placement of the flap more proxi­mally in the membranous urethra. It can be combined suc­cessfully with other tissue transfer techniques [10] and is particularly useful for recurrent strictures. [16] McAninch [11] who initially described this flap, demonstrated its success in 66 patients with a mean stricture length of 9.06 cm. [17] In 4 patients with an unsalvageable urethral plate, the flap was tubularised. Of these, only 1 patient developed a re­current stricture which was managed with an anastomotic urethroplasty. Full circumference reconstruction with both flaps and grafts provide inferior results and have been criti­cized. [17],[18],[19] In such cases a 2-stage mesh-graft urethroplasty is usually recommended. [20] We have found tubed recon­structions of particular value when the stricture extends up to the level of the verumontanum (as seen in .2 of our patients). In these circumstances a staged mesh graft ure­throplasty would be technically difficult. [8]

When penile skin is insufficient or contra-indicated (as in BXO) substitution urethroplasty for long strictures can be performed using a midline longitudinal penoscrotal flap, combined flap and graft, or multiple buccal mucosal strips. [15]

The midline penoscrotal flap can provide length up to 12­-17 cm. [1] However hairgrowth in the scrotal skin (as was seen in I of our patients) can be a troublesome complication. While applying combined tissue transfer techniques (flap + graft), it is essential to know the anatomy and vascular sup­ply of the urethra. The bulbar urethra has a bulky spongiosum and receives direct blood supply from the bulbourethral artery. The distal spongiosum is less well de­veloped and receives its blood supply from the dorsal pe­nile artery via the glans. Thus the bulbar urethra is more reliable in terms of blood supply. Hence free grafts which rely on the vascular bed for take are best applied on the bulbar urethra. [21] All our patients with free grafts were onlaid onto the bulbar urethra. We initially applied grafts as a ven­tral onlay (bladder mucosa). With the recent excellent re­sults of dorsal onlay graft urethroplasty [22],[23] our strategy has changed to both dorsal onlay for both grafts and flaps. In our patients buccal mucosal grafts were applied dorsally on the bulbar urethra in 4 patients and 1 patient with a panurethral stricture and BXO had complete urethral sub­stitution with 2 strips of buccal mucosa (6cm and 7cm) [Figure - 3]a and b. In this patient meatal stricture reconstruction was also carried out by a dorsaal application of the buccal mucosal graft as described by Kulkarni et al. [15] These au­thors have reported excellent results in single stage recon­struction of panurethral strictures due to BXO with multiple strips of buccal mucosa. Others too have successfully treated long strictures with buccal mucosa. [24],[25] Our experience with buccal mucosa has been recent and long-term results using the same are awaited.

Focally dense strictures with an unhealthy urethral plate are usually managed by converting the flap/graft into a tube at that particular area. However such situations can be man­aged by focal excision of 1-2 cm of the unhealthy urethral plate followed by a dorsal or ventral re-approximation of the cut ends. Subsequently tissue transfer can be made as an onlay (augmented floor/roof strip urethroplasty). 4 of our patients had this procedure and none reported any degree of penile shortening. If excision is limited to 1-2 cm of the urethral plate, penile shortening does not occur. However if the fo­cally dense segment is > 2 cm, then the patient should be warned regarding the possibility of some penile shortening. [26] Guralnick et al [26] have recently reported excellent results us­ing this technique in a large number of patients.

In our study recurrences were seen in patients with both combined and single tissue transfer techniques. Of these only 1 (patient with the proximal tunica vaginalis flap) had a refractory stricture. Two recurrences were successfully managed by a single visual internal urethrotomy and two with an anastomotic urethroplasty. Pseudodiverticulum fomation with resultant post-void dribbling was seen in 6 patients with ventrally applied flaps/grafts. Therefore dor­sal placement of the flaps/grafts may be more appropriate.


   Conclusions Top


Single stage reconstruction for long, complex anterior urethral strictures can be performed successfully with sin­gle or combined tissue transfer techniques. The circum­penile fasciocutaneous flap is the most versatile tissue transfer technique as it provides substantial length and can be successfully combined with free grafts, and other pro­cedures like anastomotic and augmented roof/floor strip urethroplasty. In the absence of adequate penile skin or where it is contraindicated, buccal mucosa is an excellent substitute for substitution of long strictures. By preserv­ing the urethral plate two-stage techniques can be avoided in most circumstances.

 
   References Top

1.Angermeier KW, Jordan GH, Schlossberg SM. Complex urethral reconstruction. Urol Clin North Am 1994: 21: 567-581.  Back to cited text no. 1    
2.Johanson B. Reconstruction of the male urethra in strictures. Ap­plication of the buried intact epithelium tube. Acta Chir Scand 1960: 176:1-2.  Back to cited text no. 2    
3.Turner Warwick RT. A technique for posterior urethroplasty. J Urol 1960; 83: 416-417.  Back to cited text no. 3    
4.Schreiter F, Noll F. Mesh graft urethroplasty using split thickness skin graft or foreskin. J. Urol 1989; 142:1223-1226.  Back to cited text no. 4    
5.Brendler H. Jacobson LE. Evaluation of the scrotal inlay procedure (Turner Warwick) for strictures of the deep urethra. J Urol 1971; 105: 256.  Back to cited text no. 5    
6.Colapinto V. Two-stage urethroplasty for stricture: results and tech­nical considerations. Br J Urol 1969; 41: 494.  Back to cited text no. 6    
7.Olsson CA, Krane RJ. The controversy of single versus multistaged urethroplasty. J Urol 1978; 120: 414.  Back to cited text no. 7    
8.Carr LK, Macdiarmid SA, Webster GD. Treatment of complex an­terior urethral stricture disease with mesh graft urethroplasty. J Urol 1997; 157: 104-108.  Back to cited text no. 8    
9.El Kasaby AEW. Roofing urethroplasty in the management of pan­anterior urethral stricture disease. J Urol 2000; 163 (No 4 Suppl): (Abst.) 311.  Back to cited text no. 9    
10.Wessels H, Morey AF, McAninch JW. Single stage reconstruction of complex anterior urethral strictures: combined tissue transfer tech­niques. J. Urol 1997; 157: 1271-1274.  Back to cited text no. 10    
11.McAninch JW. Reconstruction of extensive urethral strictures: circular fasciocutaneous penile flap. J Urol 1993: 149: 488-491.  Back to cited text no. 11    
12.Morey AF, McAnnich JW. Technique of harvesting buccal mucosa for urethral reconstruction. J Urol 1996; 155: 1696-1697.  Back to cited text no. 12    
13.Keating MA, Cartwright PC, Duckett JW. Bladder mucosa in ure­thral reconstructions. J Urol 1990; 144: 827-834.  Back to cited text no. 13    
14.Armenakas N, Morey AF, McAninch JW. Reconstruction of resis­tant strictures of the fossa navicularis and meatus. J Urol 1998; 160: 359-363.  Back to cited text no. 14    
15.Kulkarni SB, Kulkarni JS, Kirpekar DV. A new technique for ure­throplasty for balanitis xerotica obliterans. J Urol 1999; 161: (Ab­stract V31) 352.  Back to cited text no. 15    
16.Morey AF, Duckett CP, McAnnich JW. Failed anterior urethroplasty: guidelines for reconstruction. J Urol 1997; 158: 1383-1387.  Back to cited text no. 16    
17.McAnnich JW, Morey AF. Penile circular fasciocutaneous flap in 1-stage recosntruction of complex anterior urethral strictures. J Urol 1998; 159: 1209-1213.  Back to cited text no. 17    
18.Mundy AR. The long-term results of skin inlay urethroplasty. Br J Urol 1995; 75: 59-61.  Back to cited text no. 18    
19.Greenwell TJ, Venn SN, Mundy AR. Changing practice in anterior urethroplasty. BJU Int 1999; 83: 631-635.  Back to cited text no. 19    
20.Webster GD, Koefoot RB. Sihelnik SA. Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selec­tion. J. Urol 1985: 134: 892-896.  Back to cited text no. 20    
21.Wessels H, McAnnich JW. Current controversies in anterior ure­thral stricture repair: free graft versus pedicled skin-flap reconstruc­tion. World J Urol 1998; 16: 175-180.  Back to cited text no. 21    
22.Barbagli G, Selli C. di Cello V, Mottola A. A one-stage dorsal free graft urethroplasty for bulbar urethral strictures. Br J. Urol 1996; 78: 929-932.  Back to cited text no. 22    
23.Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture. J Urol 1999; 161: 815-818.  Back to cited text no. 23    
24.Wessels H, McAnnich JW. Use of free grafts in urethral stricture reconstruction. J Urol 1996; 155: 1912-1915.  Back to cited text no. 24    
25.Fichtner J, Filipas D, Fisch M, Hohenfellner R. Thuroff JW. Long­term follow-up of buccal mucosa onlay for urethral stricture repair. J Urol 1999; 161: (Abstract 309).  Back to cited text no. 25    
26.Guralnick ML, Webster GD. The augmented anastomotic urethro­plasty: Indications and outcome in 29 patients. J Urol 1999; 161: (Abst 31).  Back to cited text no. 26    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1], [Table - 2]



 

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