One-stage urethroplasty for complicated urethral strictures using axial penile skin island flap

Surgical repair of urethral strictures complicated by multiple scrotal/perineal urethrocutaneous fistulae (watering-can perineum) can be very problematic. The perineal/scrotal skin is either not available or is riddled with infection, fibrosis or granulomata and therefore unsuitable as a graft source. The presence of infection makes free grafts from other sites unlikely to survive. Furthermore, extensive fibrosis may prevent excision and re-anastomosis as well as internal urethrotomy. The absence of preputial skin in circumcised patients compounds these problems. We have used a one-stage, transverse vascularized cutaneous penile flap to repair 20 cases of these complicated strictures. The graft took in 100% and no absolute repair failure was registered. In spite of obvious pre-operative infection, the result of repair was judged excellent in 17 patients (85%) and very fair in 3 (15%).     

One-stage penile/preputial island flap urethroplasty for difficult posterior urethral strictures

Summary Short traumatic strictures of the membranous urethra can be repaired by excision and end-to-end urethroprostatic anastomosis. Long membranous or bulbomembranous strictures with or without associated periurethral fibrosis, abscess or urinary fistulae require substitution urethroplasty. Tubed full-thickness skin grafts have a poor chance of survival in such circumstances. Scrotal flaps are hairy, but the penile/preputial island flap, which is relatively hairless, is ideal for such reconstructions in one stage. Difficult perineal exposure led to the development of the transpubic and the abdominoperineal routes. Modification of the incision for perineal prostatectomy by dividing the posterior part of the urogenital diaphragm in the midline up to the urethra improves the exposure so that almost all such reconstructions can be done by the perineal route. A total of 21 cases are reviewed. Flap survival is 100%, but stenosis or restricture at the anastomotic sites can occur as a result of faulty technique. These can be treated by internal urethrotomy or excision and reanastomosis.     

Two-stage urethroplasty. Improved method for treating bulbomembranous strictures.

Twelve years' experience with a two-stage urethroplasty for the surgical management of severe and complicated urethral strictures in 200 patients is summarized. The techniques used, including a modification of the Johanson urethroplasty for bulbomembranous urethral strictures and for multiple strictures without splitting the scrotum, are discussed. The most usual complications of these procedures are reported, as well as how to deal with them, and long-term final results are given. The principles of these procedures are surgically sound, considering the pathology of the strictures. At no time after urethroplasty were urethral dilatations necessary in these 200 patients.     

One-stage urethroplasty for strictures: Nigerian experience

PURPOSE: To analyze the effects on voiding and complications of one-stage urethroplasty for urethral stricture. METHODS: All patients who underwent one-stage urethroplasty for stricture in two health institutions in Enugu, Nigeria, between January 1989 and December 1998, were included. The age of the patient, duration of symptoms and the cause of the stricture were noted. Retrograde urethrogram and, when necessary, micturating cystourethogram was done. Urethroplasty was either by substitution using pedicled penile skin flap or by end-to-end anastomosis. Patients were followed up monthly for 1 year during which the patient's ability to urinate satisfactorily was assessed and any complications were noted. One hundred and forty-four (144) men, aged between 11 and 76 years (mean 36.3 +/- 11.2 years), were studied. These included 121 cases who had rapidly recurring strictures after internal urethrotomy or dilatation and 23 cases of complete stricture. Etiology of the stricture included external trauma (43.8%), postinflammatory (36.1%) and iatrogenic (post-catheterization; 20.1%). Ninety-one (63.2%) strictures were in the anterior urethra, 47 (32.6%) in the posterior urethra and six (4.2%) bulbomembranous. The mean length of the strictures was 3.1 +/- 1.4 cm. RESULTS: Anastomotic urethroplasty was performed in 98 (68.1%) patients and substitution in 46 (31.9%). Hospital stay was between 12 and 14 days, except in those who developed complications. Normal voiding was achieved in 124 (86.1%) patients. Urethral fistula was encountered in five (3.5%) patients and recurrent stricture in 15 (10.4%). There was no mortality. CONCLUSIONS: One-stage urethroplasty affords an excellent cost-effective means of reconstruction of the urethra in patients with stricture of various etiologies. In our environment in particular, it avoids the fulminating infection often encountered after the first stage of a two-staged operation.     

应用口腔颊黏膜Ⅰ期修复女童复杂性前尿道缺损(附3例报告)

目的：探索颊黏膜在修复女童复杂性前尿道缺损中的应用价值。方法：采用部分耻骨劈开联合阴道前庭切口，截取相应大小的口腔颊黏膜作管状成形I期修复女童前尿道缺损3例。结果：3例女童术后均排尿通畅，最大尿流率为l9．6—24．4m1／s，平均为20．5m1／s，尿道造影示尿道通畅。结论：口腔颊黏膜具有取材方便、对患者创伤小、抗感染能力强等特性，是一种较好的尿道替代材料，尤其适合尿道狭窄段＜5cm的患者。     

Con: bulbomembranous anastomotic urethroplasty for pelvic fracture urethral injuries

Current literature remains controversial regarding whether to treat patients sustaining pelvic fracture urethral injuries (PFUIs) with primary endoscopic realignment (PER) versus suprapubic tube (SPT) placement alone with elective bulbomembranous anastomotic urethroplasty (BMAU). Success rates for PER following PFUI are wide-ranging, depending on various authors’ definitions of what defines a successful outcome. At our institution, for SPT/BMAU patients, the mean time to definitive resolution of stenosis was dramatically shorter compared to PER cases. The vast majority of PER patients required multiple endoscopic urethral interventions and/or experienced various other adverse events which were rarely noted among the SPT/BMAU group. While PER does occasionally result in urethral patency without the need for further intervention, the risk of delay in definitive treatment and potential for adverse events has led to a preference for SPT and elective BMAU at our institution.     

Buccal mucosa urethroplasty in anterior urethral strictures

Buccal mucosal graft can be used for succesfull repair in both pendulous and bulbar strictures. MATERIAL AND METHODS: We present our experience with buccal mucosal graft repair in 8 patients with onlay patch that varies from 4 to 16 cm. in length. Three pendulous, two bulbar and three panurethral strictures were repaired. These patients were observed for 36 to 60 months. RESULTS: No stricture recurrences were observed. Only one patient had lower lip paresthesia for six months.     

One-stage penile/preputial island flap urethroplasty for urethral stricture

A 1-stage urethroplasty for urethral stricture with a vascularized island of distal penile or preputial skin, which is relatively hairless, is described. The results of 27 patients treated since August 1981 are reviewed.     

Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures

PURPOSE: We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures. MATERIALS AND METHODS: Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra. RESULTS: At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group. CONCLUSIONS: Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.     

Full thickness skin graft urethroplasty for anterior urethral strictures.

Thirty-two free full thickness skin graft urethroplasties were performed over a thirty-nine-month period. Follow-up of more than six months was available in 27 patients. Results were good or fair in 26 patients (96 per cent). Only 1 patient has been classified as a failure and required reoperation.     

尿道下裂尿道成形术后尿道狭窄的处理

目的 探讨尿道下裂尿道成形术后尿道狭窄的病因及治疗方法。方法 对１９８５－１９９８年７７例尿道下裂术后尿道狭窄患者的临床资料进行回顾性分析。结果 单纯尿道扩张９例,治愈２例（２２％）;尿道扩张放钛镍合金支架２２例,治愈１７例（７７％）;狭窄段尿道切开皮肤造瘘２３例,其中１８例行二期尿道成形术,治愈１６例;５例待手术;切开狭窄段同期尿道成形术２３例,治愈１２例。     

Outcome of dorsal buccal graft urethroplasty for recurrent bulbar urethral strictures

OBJECTIVE

To audit our results of dorsal buccal mucosal graft urethroplasty for recurrent bulbar urethral stricture disease and compare them with those from specialist centres.

PATIENTS AND METHODS

Data were collected prospectively on 52 men who had urethroplasty with ≥1 year of follow‐up; failure was defined as the need for further intervention.

RESULTS

The mean (range) age of the patients was 39 (19–61) years and 23 (45%) had an identifiable cause for their stricture. The mean (range) stricture length was 3.5 (1.5–6) cm and was associated with moderate or severe spongiofibrosis in 38 (73%) men. Ten (19%) men had minor complications after surgery. The mean (range) follow‐up was 34 (12–80) months, with the mean maximum urinary flow rate increasing from 6 to 24 mL/s after surgery. The surgery failed, requiring dilatation or urethrotomy, in seven (14%) men at a mean (range) of 25 (15–50) months after urethroplasty, giving an overall success rate of 86%.

CONCLUSION

This prospective audit of dorsal buccal patch augmentation urethroplasty for bulbar strictures shows an equivalent outcome to the standard set by the expert originators, suggesting that is transferable to less specialized centres. The efficacy, low complication rate, short hospital stay and general applicability of the technique encourage its use for all men with recurrent bulbar stricture disease, but formal comparison with other options in randomized trials, including cost‐effectiveness analysis, is needed.     

Tunica albuginea urethroplasty for anterior urethral strictures: A urethroscopic analysis

Objective:   To assess the efficacy of tunica albuginea urethroplasty (TAU) for anterior urethral strictures.
Methods:   We assessed 206 patients with anterior urethral strictures who underwent TAU. The procedure involves mobilization of strictured urethra and laying it open with a dorsal slit. Edges of the slit-open urethra are sutured to edges of the urethral groove with a silicon catheter in situ . Thus in neourethra, the roof is formed by tunica albuginea of the urethral groove. Results were assessed at 6, 12, 24 and 36 months by comparative analysis of patient satisfaction along with retrograde urethrogram, urethrosonogram, uroflowmetry, and were categorized as good, fair and poor. Good and fair results were considered as successful. Thirty patients were taken for postoperative urethroscopic analysis to allow better understanding of both successful and failed cases.
Results:   Postoperative evaluation at 6 months showed a 96.6% success rate, which decreased to 94.7% at 1 year, 93.2% at 2 years and over 90% at the end of 3 years. The overall failure rate was 9.2%, which required revision surgery. Urethroscopic visualization of the reconstruction site showed wide, patent and distensible neourethra uniformly lined by urothelium over roof formed by tunica albuginea of the corpora cavernosa in successful cases. Failure cases showed diffuse fibrotic narrowing or circumferential scarring.
Conclusion:   Tunica albuginea is a locally available distensible tissue, sufficient to maintain the patency of the neourethra, without any graft or flap. TAU is easier and useful when patients have unhealthy oral mucosa due to tobacco chewing.