Urethrectomy in the Male
The indications for urethrectomy include carcinomatous involvement of the urethra. This can be done at the completion of a cystectomy or performed after subsequent urethral recurrence or, more commonly, staged after cystectomy.
The patient should be placed in a lithotomy position. For most patients, hip flexion at 60 to 90 degrees should suffice; however, an exaggerated lithotomy can be used if additional exposure is necessary ( Fig. 50.1 ).
After placement of the Foley catheter, a vertical perineal incision can be made over the palpable urethral bulb ( Fig. 50.2 ). The incision can extend onto the base of the scrotum to provide better exposure; however, it is rarely needed because the distal urethra can easily be exposed because of the scrotal skin mobility. If greater exposure is necessary, an inverted U incision or a midline incision with lateral extension can be performed (see Fig. 50.2 ). After the skin incision is made, a Scott ring retractor or similar retractor works well to expose the urethra ( Fig. 50.3 ).
Divide the subcutaneous tissue and the bulbospongiosus muscle in the midline until the central perineal tendon and corpus spongiosum are encountered. Dissect laterally around the corpus spongiosum ( Fig. 50.4 ). Grasp the urethra and Foley catheter and perforate behind the urethra with a right-angle instrument. A large Penrose drain can be passed behind the urethra to assist in retraction ( Fig. 50.5 ). The corpus spongiosum should be completely isolated ( Fig. 50.6 ).
Retractor hooks can be moved farther proximally along the urethra to facilitate exposure of the distal urethra. The distal urethra should be separated from the corpora cavernosa. Inadvertent injury of the corpora cavernosa can be closed with interrupted Vicryl sutures. Dissection of the distal urethra is greatly facilitated by incising the surrounding investing fascia of the corpus spongiosum with Metzenbaum scissors in the midline ( Fig. 50.7 ). Side retraction of the urethra with the Penrose drain will facilitate exposure of the urethra and its attachments.
Invaginate the penis to the base of the glans. This can be facilitated with downward retraction of the Penrose drain around the urethra ( Fig. 50.8 ). Carry the dissection up to the base of the glans. When this step is completed, let the penis return to its normal position and proceed to excise the distal urethra to remove the entire urethra en bloc.