Int Urol Nephrol (2007) 39:497–503 DOI 10.1007/s11255-006-9029-1
ORIGINAL PAPER
Dorsal on-lay preputial graft urethroplasty for anterior urethra strictures repair Demetrios Radopoulos Æ Constantinos Tzakas Æ Georgios Dimitriadis Æ Ioannis Vakalopoulos Æ Stavros Ioannidis Æ Ioannis Vasilakakis
Received: 27 March 2006 / Accepted: 28 April 2006 / Published online: 17 February 2007 Ó Springer Science+Business Media B.V. 2007
Abstract Objectives To report the long-term results and evaluate the effectiveness of the dorsal on-lay preputial graft urethroplasty in patients suffering from anterior urethra strictures. Methods A total of 21 male patients, mean age 46.3 years (range 17–67), with anterior urethral strictures, underwent the dorsal on-lay preputial graft urethroplasty during the last 8 years, from October 1997 to September 2005. Strictures were located in bulbar urethra in 16 patients and in penile urethra in the remaining 5. The aetiology the stricture was traumatic injury of the anterior urethra in 12 patients and iatrogenic in 9 patients. A direct vision dorsal urethrotomy and the insertion of an urethral Foley catheter right before the procedure, facilitated the corpus spongiosum dissection and the preparation for urethroplasty. A voiding cystogram was performed on the day of urethral catheter removal to
D. Radopoulos Æ C. Tzakas Æ G. Dimitriadis Æ I. Vakalopoulos Æ S. Ioannidis Æ I. Vasilakakis 1st Department of Urology, Aristotle University of Thessaloniki, ‘‘G.Gennimatas’’ General Hospital, Thessaloniki, Greece G. Dimitriadis (&) ‘‘G.Gennimatas’’ General Hospital, Dousmani str. 30, GR-546 44 Thessaloniki, Greece e-mail:
[email protected]
exclude extravasation and estimate the postoperative result. Results Mean follow-up time has been 49.9 months (range 6–95) and the outcome was favourable in 15 patients (71.43%). There were 3 recurrences in penile urethra strictures managed conservatively and three in bulbar urethroplasties, treated with internal urethrotomy followed by urethral dilatations. Conclusion Our results indicate that dorsal onlay urethroplasty using preputial graft is an easy to learn and perform procedure, and offers the patient durable results with rather minimal complications. Keywords Urethra Æ Stricture Æ Urethroplasty Æ Preputial graft
Introduction Surgical repair of anterior urethral strictures continues to be a challenge and the excision of the stricture followed by an end-to-end anastomosis is the acceptable ideal method. When a stricture is too long, patch graft urethroplasty has been considered as the best alternative [1, 2]. The application of the graft ventrally, along the incised stricture and over the corpus spongiosum, often lacks the adequate support of a fixed bed and it favours graft folding. This reduces the
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opportunity for graft neovascularization, especially in strictures located in the penile urethra and decreases the caliber of the repaired urethra. Less commonly it may form a sacculation at the graft site [3, 4]. Generally penile skin, applied as a graft or island flap, is considered to be the best material for urethral reconstruction [5]. When the local skin is insufficient other donor sites, such as buccal or bladder mucosa or extragenital skin, are being used [6–8]. We present our experience from anterior urethra strictures surgical repair via the dorsal on-lay preputial graft urethroplasty, proposed by Barbagli et al. [9]. This technique allows the graft to be spread and fixed onto a more secure bed that improves the chance of neovascularization and also reduces the possibility of graft shrinkage and sacculation.
Patients and method From October 1997 to September 2005, 21 male patients 17– 67 years old (mean age 46.3 years), who suffered from anterior urethra strictures, underwent the dorsal on-lay preputial graft urethroplasty (Fig. 1). Strictures were located in bulbar urethra in 16 patients, extended into the penile urethra in two of them, but in the remaining 5 patients strictures were located in the penile Fig. 1 Schematic diagram of the repair of a bulbar urethral stricture. The strictured segment of the urethra has already been opened along its dorsal surface and separated from the corpora cavernosa (A). The fenestrated preputial skin graft has been sutured to overlying undersurface of corporal bodies (B)
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urethra. The aetiology of the stricture was traumatic in 12 patients and iatrogenic in 9 patients. Four among the latter have been subjected to coronary by-pass operations and five underwent prostatectomy, open in 3 and TUR in 2. All patients had received previous conservative treatment, urethrotomy once or twice, in most of them and/or urethral dilatations for several times in the others. Stricture anatomy was defined by retrograde and voiding urethrogram in all patients. Stricture location and urethra mobilization was facilitated by a direct vision dorsal urethrotomy at the 12 o’clock position, applied to all patients right before the urethroplasty. Stricture incision was extended for 1–2 cm into the healthy urethra proximal and distal to the stricture and a Foley catheter of appropriate size (14–20 Fr) was left. A perineal approach in the lithotomy position was used for the bulbar stricture cases through an incision on the midline of the perineum while the penile urethra strictures were approached through a circumferential incision to the coronal sulcus of the glans and penile skin deglovement. A combination of the above two incisions was applied in two cases of proximally located long penile strictures to achieve better exposure of the whole penile urethra. A full-thickness preputial skin graft of adequate width (2–2.5 cm.) and length was harvested (Fig. 2), spread to overly the
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ventral surface of corpora cavernosa and fixed with interrupted 4.0 vicryl sutures. Mean graft length was 4.9 cm (range 3–7) in the bulbar and 7.4 cm (range 6–10) in the penile strictures. The margins of the previously opened urethra were sutured in a running way to the edges of the graft, using the same suture material (VicrylÒ 4.0). Right before the suture the preputial graft was fenestrated by several holes, as it is shown in two
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cases (Figs. 3 & 4). All patients except two were discharged on third post-op day under oral antibiotics, which were continued until a few days after catheter removal. Two recently treated adult patients with distally located penile strictures were discharged home the morning after the operation. The repair was done under local anaesthesia in one of them and it was also combined with a flip-flap operation for simultaneous reconstruction of his anterior penile hypospadias, in the other.
Results There were no early complications (wound infections or heamatomas) and the urethroplasty was effective. The urethral catheter was kept for 12 days and a voiding urethrogram was
Fig. 2 Preparation of the preputial skin graft (above) and its meticulous denudation from the underlying subcutaneous tissue (below)
Fig. 3 Fixation of the graft on the undersurface of the corpora cavernosa, above the open stricture portion. Graft fenestration is evident
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Fig. 5 Retrograde urethrogram in a patient with bulbar urethra stricture before (above) and a year after the repair (below)
Fig. 4 The left margin of the opened urethra was sutured to the left side of the fixed graft. The procedure is repeated on the opposite side
performed right after catheter removal (Figs. 5 & 6). In case of any extravasation (that was noticed in four patients), a catheter was reinserted and kept for 5 more days. Otherwise, uroflowmetry and a retrograde urethrogram was performed 3 or 4 months later and a year after as well. Urethra caliber was routinely checked periodically by urethral dilators of appropriate size. The outcome was favourable in 15 patients (71.43%) with a follow-up of 6 to 95 months (mean 49.90 months). An adult patient with the very long iatrogenic stricture in the penile urethra, presented with dysuria and poor urinary stream 2 months after the operation, due to a mild decrease of urethral caliber revealed in retrograde urethrogram. He underwent urethral dilatations twice in three months and both his
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symptoms and the flow improved, but ever since he had to be routinely managed by urethra dilatations every 6 months. This was the first case we have treated and the graft was not fixed on the corpora, but the good healing of urethroplasty relied only on the compressive penile dressing, which remained for 8 days. Five more patients presented with dysuria and gradual weakening of the urinary stream. In two of them with iatrogenic post-prostatectomy strictures in the bulbar urethra, a ring stricture on the proximal end of the urethroplasty proved to be the cause and it was successfully treated with urethrotomy followed by urethral dilatations, 4 and 6 months after the repair, respectively. Urethral dilatations were also successfully applied to the remaining three patients with post-operative obstructive symptoms, the first one with a small stricture on the proximal end of urethroplasty in the bulbar urethra and the others with the repair of penile urethra stricture.
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Discussion
Fig. 6 Preoperative retrograde (above) and postoperative voiding cystourethrography (below), in a 17 years old patient, with a traumatic stricture in the bulbar urethra
In addition to the above patients one 8-yearold boy, with a 5 cm long iatrogenic stricture in bulbar and proximal penile urethra, was treated with the same method. During the 86 months follow-up time, his urethra remains patent with a normal voiding pattern.
Fig. 7 Schematic diagram of the excisional augmented anastomotic urethroplasty. The most hard and dense portion of the stricture is excised (A) the two parts of the urethra are mobilized (B), dorsally spatulated (C), and
Urethral strictures continue to present a major cause of morbidity among the male population. Even though the epidemiology has been diverted from the infectious to the traumatic cause, there is an ongoing effort for technique refinement and better results. There are various methods for treating urethral stricture disease. The method of choice is dictated mainly by the length of the stricture, although other factors, such as surgeon’s experience and preference, stricture aetiology, stricture location, previous treatments, and the degree of spongiofibrosis, play a decisive role. Although both dilatations and internal urethrotomy have been proved to present identical long-term results for treating urethral strictures < 1 cm, excision of stricture with a primary, spatulated, tension-free end-to-end anastomosis remains the acceptable ideal method for strictures < 2 cm long. For strictures of 2–4 cm, the method of excisional augmented anastomotic urethroplasty could be used (Fig. 7). The most hard and dense portion of the stricture is excised (up to 2 cm) and the two parts of the urethra are dorsally spatulated and reanastomosed ventrally. The urethra lumen is augmented with a graft (preputial, buccal or other), that is fixed on the undersurface of the corpora [1, 2, 10–12]. In strictures of 2–4 cm or longer where excision is not feasible, dorsal on-lay urethroplasty alone is preferable [13–15]. Dorsal on-lay preputial graft urethroplasty is a procedure with a relatively acceptable learning curve, which is facilitated by the direct visual
re-anastomosed ventrally (D). The urethra lumen is being augmented with a preputial graft, which is fixed on the under-surface of the corpora (E)
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urethrotomy, performed right before the reconstruction. Internal urethrotomy allows the stricture and the nearby urethra to be opened at the appropriate site and the introduced urethral catheter facilitates the preparation and mobilization of the corpus spongiosum, that has to be completely separated from the adjacent corpora cavernosa [16]. The corpora cavernosa provide a secure and stable bed for the graft to be revascularized. Especially for strictures located in bulbar urethra, the dorsal approach is considered to be a more anatomical one than the ventral approach because the urethral lumen is situated more dorsally in this portion, close to the corpora cavernosa. Ventral on-lay graft urethroplasty although popular until recently, has been proved to have specific disadvantages that dorsal on-lay approaches seem to overcome. Ventrally placed grafts may lack the support of a stable surface and may suffer from inadequate neo-vascularization. This may result in graft shrinkage and/or sacculation inducing urethral stricture recurrence and/ or pseudo-diverticulum formation [11, 14]. Nevertheless the method has its supporters, arguing that the incidence of those complications is lower than it is reported [17–19]. Moreover, tissue damage and bleeding is not significant because it requires less dissection of the spongy tissue. Although the length of the stricture is not a contraindication for dorsal on-lay urethroplasty, its primary indication is strictures of the pendulous urethra longer than 1 cm, where an end to end anastomosis could cause the formation of secondary chordee. Contraindications are extensive spongiofibrosis of the corpus spongiosum, especially with obliteration of urethral lumen, where the repair with complex staged reconstruction could be the appropriate method [13]. There is a plethora of tissues that can be used as grafts or flaps, but the two main donor sites for graft harvesting is buccal mucosa or preputial and penile skin. We favour the use of preputial skin graft not only because our results are approximately the same with dorsally placed buccal mucosa grafts, but because it is a tissue familiar to the urologist, located very close to the surgical field, that can easily be processed. It is imperative that all subcutaneous tissue has to be removed from the graft, because its survival depends solely
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on its ability to receive nutrients by diffusion for 24 or 48 h, until inosculation is established by the neovasculature from the graft bed. In their most recent paper, Barbagli et al. reported the results of 71 months follow up in 45 patients with bulbar urethra strictures [20]. Their results were less optimistic, because, with time, the success rate dropped from 100% in 1996 to 73% in 2003. This led to scepticism about the long term results expected in the future. Outcome was favourable in 16 of our patients (72.72%) for a shorter mean follow-up of 52 months (range 6– 86 months). Our results should be interpreted in the light of the fact that we used strict selection criteria for our patients, who have been operated by a single surgeon resulting in minimization of operator dependent variations. Conclusions Dorsal on-lay preputial graft urethroplasty is an easy and versatile procedure that is facilitated even more by the direct vision urethrotomy performed right before the reconstruction. The latter permits the stricture and the nearby urethra to be opened at the appropriate site and the introduced urethral catheter facilitates the dissection and mobilization of the corpus spongiosum, which has to be separated completely from the adjacent corpora cavernosa. The technique offers the advantage of fixation of the spread graft on a firm and well-vascularized bed, which most possibly promotes neovascularization. Spread fixation of the graft reduces also the possibility of shrinkage and avoids its sacculation with the consecutive problems of accumulation of urine and semen, as it frequently happened when the graft was applied ventrally. The early outcome is promising, but the urethroplasty has yet to stand the test of time, as it has also been noticed by surgeons with broad experience in urethral surgery. References 1. Zinman L (1999) Surgical management of anterior urethral strictures. In: Ehrlich, Alter (eds) Reconstructive and plastic surgery of the external genitalia, Philadelphia, WB Saunders Co, chapt 68, pp 369–384
Int Urol Nephrol (2007) 39:497–503 2. Wessels H, McAninch JW (1996) Use of graft in urethral stricture reconstruction. J Urol 155:1912 3. Blum JA, Feeney MJHowe GE, Steel JF (1982) Skin patch urethroplasty: 5-year followup. J Urol 127:909 4. Brigman JA, Deture FA (1982) Giant urethral diverticulum after free full-thickness skin graft urethroplasty. J Urol 127:909 5. Wessels H, Morey AF, McAninch JW (1997) Single stage reconstruction of complex anterior urethral strictures: combined tissue tranfer techniques. J Urol 157:1271 6. Hendren WH, Reda EF (1986) Bladder mucosa graft for construction of male urethra. J Ped Surg 21:189 7. Andrich DE, Mundy AR (2001) Substitution urethroplasty with buccal mucosal free grafts. J Urol 165:1131–1134 8. Hendren WH, Crooks KK (1980) Tubed free graft for construction of male urethra. J Urol 123:858 9. Barbagli G, Selli C, Tosto A, Palminteri E (1996). Dorsal free graft urethroplasty. J Urol 155:123 10. Guralnick ML, Webster GD (2001) The augmented anastomotic urethroplasty. Indications and outcome in 29 patients. J Urol 165:1496–1501 11. Iselin CE, Webster GD (1999) Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture. J Urol 161:815–818 12. Andrich DE, Leach CJ, Mundy AR (2001) The Barbagli procedure gives the best results for patch
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