Reconstruction of the Fossa Navicularis

True strictures of the fossa navicularis represent a unique challenge for the reconstructive surgeon. It is essential that the etiology of the meatal stenosis and fossa stricture be understood to be able to achieve satisfactory functional and cosmetic outcomes. The fossa stricture that follows urethral instrumentation, such as transurethral resection of the prostate (TURP), is a much different process than the fossa stricture associated with lichen sclerosus/balanitis xerotica obliterans (LS/BXO).

Strictures associated with LS/BXO rarely respond well to conservative measures such as dilation, urethrotomy, or meatotomy. These should be approached with open reconstructive techniques and can be corrected with interposition of nonfibrotic tissue to prevent recurrence. Alternatively, initial endoscopic management followed by chronic dilation can be considered to manage the stricture.

In contradistinction, meatal stenosis of childhood is in essence a fusion of the ventral aspect of the normal meatus secondary to balanitis. These stenoses respond very nicely to meatotomy.

Skin Flap Techniques

These procedures are founded on the Y-V principle and are useful for isolated short fossa strictures. Consistent reconstructive outcomes can be achieved with these techniques, particularly for patients with strictures following instrumentation such as after TURP. These techniques are useful in strictures that are not associated with LS/BXO; the use of skin flaps in these patients has an unacceptably high failure rate.

Cohney

Cohney in 1963 described a penile flap procedure using a circumferentially elevated random skin flap. The procedure does open the distal urethra well, but the patient is left with a poor cosmetic outcome and retrusive meatus.

1.

A traction suture is placed. The area of meatal stenosis and fossa stricture is opened ventrally. A random flap oriented transversely on the penile skin is elevated ( Fig. 92.1 ).

FIGURE 92.1

Transversely oriented random flap.

(From Jordan GH, Schlossberg SM. [2007]. Surgery of the penis and urethra. In: Wein AJ [ed]. Campbell-Walsh urology, 9th ed. Philadelphia: Elsevier.)
2.

The flap is spatulated into the meatotomy defect. Distally the edge of the glans is sutured to the edge of the opened stenotic fossa navicularis, and the flap donor site is closed per primum ( Fig. 92.2 ). Urine is diverted with a Foley catheter for 24–48 hours.

FIGURE 92.2

Flap is rotated into defect.

(From Jordan GH, Schlossberg SM. [2007]. Surgery of the penis and urethra. In: Wein AJ [ed]. Campbell-Walsh urology, 9th ed. Philadelphia: Elsevier.)

Blandy-Tresidder

In 1967 Blandy and Tresidder devised a flap reconstruction that is elevated based on the vascularity of the dartos fascia. The procedure provides excellent functional results but provides only modest improvement over the cosmetic outcomes of Cohney’s earlier technique, generally leaving the patient with a coronal meatus.

1.

A traction suture is placed. The area of meatal stenosis and fossa stricture is opened ventrally. A V-shaped flap is dissected from the distal penile skin ( Fig. 92.3 ). This flap is based on random vascularity.

FIGURE 92.3

Stricture is opened and midline skin flap is developed.

(From Jordan GH, Schlossberg SM. [2007]. Surgery of the penis and urethra. In: Wein AJ [ed]. Campbell-Walsh urology, 9th ed. Philadelphia: Elsevier.)
2.

The V-flap is then spatulated into the meatotomy. The glans edge is sutured to the edge of the stenotic portion of the distal urethra. The penile skin is then reapproximated to the edge of the glans ( Fig. 92.4 ). Urine is diverted with a Foley catheter for 24 to 48 hours.

FIGURE 92.4

Skin flap is advanced into defect, resulting in a coronal meatus.

(From Jordan GH, Schlossberg SM. [2007]. Surgery of the penis and urethra. In: Wein AJ [ed]. Campbell-Walsh urology, 9th ed. Philadelphia: Elsevier.)

Brannen

A modification of the Blandy flap, Brannen et al. (1976) described a more aggressive flap elevation technique. This method is aimed at trying to create a cosmetically better appearance of the glans and distal penile skin than that of the previously described procedures. The process of advancement is mechanically inefficient, and in most cases, offers little improvement with regard to cosmetic results.

1.

A glans traction stitch is placed. The stenotic meatus and fossa navicularis are opened and spatulated into the normal distal urethra. An accentuated V-flap is dissected from the distal penile skin and is advanced. The flap is spatulated into the meatotomy, but then sutured to the edge of the stricturotomy, out toward the tip of the glans penis ( Fig. 92.5 ). This procedure requires significant advancement of the ventral penile skin.

FIGURE 92.5

Midline dartos-based flap with more aggressive advancement.

(From Jordan GH, Schlossberg SM. [2007]. Surgery of the penis and urethra. In: Wein AJ [ed]. Campbell-Walsh urology, 9th ed. Philadelphia: Elsevier.)
2.

The glans penis is then reapproximated to the edge of the advanced flap, and the penile skin is closed per primum to the coronal margin ( Fig. 92.6 ).

FIGURE 92.6

Flap is sutured; penile skin is advanced onto ventral glans.

(From Jordan GH, Schlossberg SM. [2007]. Surgery of the penis and urethra. In: Wein AJ [ed]. Campbell-Walsh urology, 9th ed. Philadelphia: Elsevier.)

De Sy

This technique is designed to create a cosmetically normal appearance of the glans penis and distal penile skin. De Sy (1984) further modified the Blandy-Brannen flap by using a longitudinal skin island carried on a dartos fascia pedicle. The process of advancement is mechanically inefficient; however, De Sy reports excellent results in a relatively large series of patients. In general, the vascularity is probably random.