Panurethral stricture, involving the penile and bulbar urethra, is seen across the world .It is a complex disease with a relative paucity of literature on the subject. In India, Lichen Sclerosus is the most common cause of panurethral stricture followed by iatrogenic causes. The article presents the authors’ experiences of Panurethral stricture repair using a single stage, One side dissection, dorsal onlay repair with oral mucosa graft.
Key points
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Panurethral structure is a complex and challenging issue.
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Staged urethroplasty was preferred in past.
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Lichen sclerosus is a genital skin disease, and staged urethroplasty is not preferred.
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Single-stage buccal graft procedures have an advantage over staged procedures and flaps.
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Multicenter published review concludes that panurethral structure treated in most high-volume centers with a single-stage dorsal onlay buccal graft augmentation urethroplasty has superior results over staged urethroplasty or flap procedures.
Video content accompanies this article at http://www.urologic.theclinics.com .
Urethroplasty for panurethral urethral stricture
Introduction
The surgical treatment of urethral strictures varies according to cause, location, and length of stricture. Treatment of strictures involving the bulbar urethra is relatively well defined. However, management of long-segment urethral stricture, or panurethral stricture disease, is challenging, and the literature on the subject is not abundant.
Panurethral stricture involves the full length of the urethra from meatus until the most proximal bulb. The incidence of panurethral strictures is increasing. Most panurethral strictures in the Indian subcontinent are due to lichen sclerosus. Iatrogenic causes are also on the increase. Iatrogenic causes include urethral catheterization, cystourethroscopy, transurethral resection, and previous urethral surgeries.
Review of literature suggests the use of staged Johanson’s urethroplasty and the use of flaps for these complex patients. Because lichen sclerosus is a disease of genital skin, local skin flaps or staged urethroplasty is best avoided because the disease can recur in the tubularized urethra. The late 1990s saw the revolution of buccal mucosa urethroplasty. Subsequently panurethral strictures started being treated with augmentation using buccal grafts. The authors present the management algorithm for panurethral strictures ( Fig. 1 ).
Evaluation of Patient
Symptomatic stricture disease usually presents with decreased flow associated with other lower urinary tract symptoms. Patients may have recurrent urinary tract infections. Usually strictures with lichen sclerosus have a long-standing history. Iatrogenic strictures tend to present early. Significant numbers of iatrogenic strictures are nearly obliterative in nature, and the patient could be referred with a suprapubic tube.
Many patients have a history of direct visual internal urethrotomy and dilatations. Uroflowmetry, ultrasonography, and cystourethroscopy are important adjuncts in the diagnosis of panurethral stricture disease. Ultrasonography is done to evaluate upper tract. Retrograde urethrography ( Fig. 2 ) and voiding cystourethrography determines the location, length, and severity of the stricture. It is important to note that the membranous urethra does not have spongiosum and is almost never involved in panurethral stricture. However, the bulbar urethra may be involved up to the bulbomembranous junction.
Urethroplasty for panurethral urethral stricture
Introduction
The surgical treatment of urethral strictures varies according to cause, location, and length of stricture. Treatment of strictures involving the bulbar urethra is relatively well defined. However, management of long-segment urethral stricture, or panurethral stricture disease, is challenging, and the literature on the subject is not abundant.
Panurethral stricture involves the full length of the urethra from meatus until the most proximal bulb. The incidence of panurethral strictures is increasing. Most panurethral strictures in the Indian subcontinent are due to lichen sclerosus. Iatrogenic causes are also on the increase. Iatrogenic causes include urethral catheterization, cystourethroscopy, transurethral resection, and previous urethral surgeries.
Review of literature suggests the use of staged Johanson’s urethroplasty and the use of flaps for these complex patients. Because lichen sclerosus is a disease of genital skin, local skin flaps or staged urethroplasty is best avoided because the disease can recur in the tubularized urethra. The late 1990s saw the revolution of buccal mucosa urethroplasty. Subsequently panurethral strictures started being treated with augmentation using buccal grafts. The authors present the management algorithm for panurethral strictures ( Fig. 1 ).
Evaluation of Patient
Symptomatic stricture disease usually presents with decreased flow associated with other lower urinary tract symptoms. Patients may have recurrent urinary tract infections. Usually strictures with lichen sclerosus have a long-standing history. Iatrogenic strictures tend to present early. Significant numbers of iatrogenic strictures are nearly obliterative in nature, and the patient could be referred with a suprapubic tube.
Many patients have a history of direct visual internal urethrotomy and dilatations. Uroflowmetry, ultrasonography, and cystourethroscopy are important adjuncts in the diagnosis of panurethral stricture disease. Ultrasonography is done to evaluate upper tract. Retrograde urethrography ( Fig. 2 ) and voiding cystourethrography determines the location, length, and severity of the stricture. It is important to note that the membranous urethra does not have spongiosum and is almost never involved in panurethral stricture. However, the bulbar urethra may be involved up to the bulbomembranous junction.
Surgical techniques of panurethral repairs
Johanson’s Staged Urethroplasty
The classic 2-stage method was developed in the 1950s by Bengt Johanson. The Johanson procedure is based on marsupialization of the strictured urethra, followed by a second surgical stage approximately 4 to 6 months after the first stage has healed. In the past, scrotal or perineal skin was used for urethral reconstruction. The great achievement of Johanson’s technique was its use in all types of strictures, apart from initiating an era of urethral reconstructive surgery. The drawbacks of this technique resulted from the use of hair-growing scrotal and perineal skin, which leads to chronic urinary tract infection, abscesses, stone formation, fistulation, sacculation, and diverticula formation in the reconstructed urethra.
In the 1980s, Schreiter and Noll reported a 2-stage mesh graft procedure in an attempt to avoid the use of scrotal or perineal skin by using a hairless skin graft, which is transferred in a 2-stage procedure. Although this technique can be used in every type of stricture, apparently its best indication is in complex strictures, especially associated with severe tissue scarring and absence of healthy penile skin for urethral reconstruction.
Flaps
Several flaps have been described and used in panurethral stricture reconstruction. Quartey from Ghana described a penile fasciocutaneous skin flap in 1983. It is so called because the incision on the penis resembles the letter Q. The Q flap is outlined with the penis on stretch and the penis degloved, meticulously preserving the blood supply on the tunica dartos pedicle. The Q-flap is sewn into place after ventral urethrotomy as an onlay flap with running absorbable suture. The fossa navicularis is typically reconstructed through a glans-wings or a glans-preserving technique. Once the pendulous portion of the onlay flap is sewn in, the patient in repositioned into the lithotomy position, the flap is transferred to the perineum through a scrotal tunnel wide enough to accommodate loose passage of the flap.
In 1993, McAninch described the circular fasciocutaneous penile flap for the reconstruction of extensive urethral stricture. Circular fasciocutaneous penile flap originates on the distal penis and uses Buck’s fascia as the major vascular supply. He reported his results with the use of this flap for 1-stage reconstruction of complex anterior urethral strictures involving long penile and also bulbar urethral strictures in 66 men. The stricture length measured up to 24 cm (average 9.08 cm). The flap was used as an onlay procedure and tubularised flap for urethral substitution. In some cases, additional adjunctive tissue transfer and proximal graft placement was required. Initial success rate was 79%, rising up to 95% after an additional procedure. Recurrent strictures occurred usually at the proximal and distal anastomotic sites. The penile circular fasciocutaneous flap reliably provided 12–15 cm of length for reconstruction in most patients, even though approximately 90% had been previously circumcised. The less favorable results were seen in patients after flap tubularization for urethral replacement. Because of compartment syndrome noted in 2 different cases due to prolonged exaggerated lithotomy position (usually occurs if the patient remains in this position more than 5 hours), the authors begin the operation with flap harvesting with the patient in the supine position, thereby reducing exposure to the lithotomy position by 2-3 hours.
The potential major advantage of these flap procedures is to allow a single-stage reconstruction of long-segment and complex strictures and to avoid the need for additional, morbid, time-consuming tissue transfer techniques.
These two procedures require plastic surgery training. A common complication with the above two flaps, particularly with inexperienced surgeons, is necrosis of penile skin proximal to the flap. In some instances, this penile skin necrosis may lead to wound infection and ultimately to disruption of the flap and necrosis.
Major challenge of flaps is the meticulousness needed to preserve the pedicle and blood flow without causing necrosis to the remaining penile skin. Not many urologists are trained in plastic surgical techniques. Lichen sclerosus is a disease of genital skin. If penile skin flap is used in reconstruction of urethra the risk of failure is very high. In Staged urethroplasty what is essentially tubularised is the penile skin and again this technique cannot be used in Lichen sclerosus. Best suited option which can be used in all patients with panurethral strictures is oral mucosa graft augmentation urethroplasty.
The use of grafts in urethral reconstruction has become a popularized surgical option worldwide. They are quick and relatively easier to harvest and deploy. The widespread popularity of oral mucosa in urethral reconstruction has similarly allowed the introduction of new techniques in long-segment and panurethral stricture repair.
Single-Staged Buccal Graft Urethroplasty
Staged reconstructions are associated with significant inconvenience to some patients, exposing them to an increased risk of morbidity due to multiple general anesthetics. In addition, revision is common after 2-stage operations, and in one series, half of the patients ended up needing a 3-stage repair. Kulkarni and colleagues published a pioneering technique of single-stage augmentation urethroplasty using oral mucosa graft (OMG) through a perineal incision ( [CR] ).
The patient is nasally intubated, and 2 teams work simultaneously at the donor and recipient site, with separate sets of instruments. The oral mucosa is harvested from both cheeks as described by Kulkarni and colleagues. The patient is placed in simple lithotomy position, with heels carefully placed in Yellofin stirrups (Allen Medical Systems, Acton, MA, USA) and no pressure on the calves, to avoid peroneal nerve injury. The suprapubic, scrotal, and perineal skin is shaved, disinfected using chlorhexidine, and draped. Preoperatively, urethroscopy is performed using a 6-French rigid ureteroscope. A 3-French guidewire is inserted. Methylene blue is injected into the urethra, and a midline perineal incision is made. The bulbar urethra is dissected, only on the left side of patient, from the corpora cavernosa. The bulbospongiosus muscle and central tendon of the perineum are left intact ventrally. The dorsal aponeurosis of the bulbospongiosus is approached by dissecting around the muscle and incised, allowing access to the dorsal urethra ( Fig. 3 A). The dissection is taken across the midline. On the right, the urethra remains attached to the corpora cavernosa for its full length, preserving its neurovascular supply.
Related posts:
Management of Urethral Strictures
Definition of Successful Treatment and Optimal Follow-up after Urethral Reconstruction for Urethral Stricture Disease
Cost-effective Strategies for the Management and Treatment of Urethral Stricture Disease
The Nontransecting Approach to Bulbar Urethroplasty
Treatment of Radiation-Induced Urethral Strictures
Effect of Lichen Sclerosis on Success of Urethroplasty
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