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CASE REPORT |
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| Year : 2019 | Volume
: 35
| Issue : 2 | Page : 159-160 |
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Turner-Warwick scrotal drop back procedure as a revision perineal urethrostomy
Yogesh Boddepalli1, Malakondareddy Kota2, Anjinaik Banavath3
1 Department of Urology, Chakradhar Hospitals, Rajahmundry, Andhra Pradesh, India
2 Department of Urology, Sanghamitra Hospital, Ongole, Andhra Pradesh, India
3 Department of Urology, KIMS, Amalapuram, Andhra Pradesh, India
| Date of Submission | 14-Nov-2018 |
| Date of Acceptance | 25-Dec-2018 |
| Date of Web Publication | 1-Apr-2019 |
Correspondence Address:
Yogesh Boddepalli
Department of Urology, Chakradhar Hospitals, Rajahmundry, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/iju.IJU_345_18
 Abstract | | |
Stomal stenosis post perineal urethrostomy (PU) is a common problem. Management options for patients with PU stomal stenosis include dilatation, buccal mucosal augmentation of stoma, PU revision, and continent catheterizable stoma. In the present case, Turner-Warwick scrotal drop back procedure was performed as revision PU.
How to cite this article:
Boddepalli Y, Kota M, Banavath A. Turner-Warwick scrotal drop back procedure as a revision perineal urethrostomy. Indian J Urol 2019;35:159-60 |
| Introduction | |  |
Perineal urethrostomy (PU) is the surgery of choice after total penectomy and urethrectomy and is also used as the last resort for recurrent strictures and for complex posterior urethral strictures.[1] Stomal stenosis post PU is a common problem. Management options for patients with PU stomal stenosis are dilatation, buccal mucosal augmentation of stoma, PU revision, and continent catheterizable urinary diversion.[1] In the present case, Turner-Warwick scrotal drop back procedure (TWSD) was used to revise PU. The aim of this article is to describe the technical aspects of TWSD.
| Case Report | | |
A 67-year-old male with a prior history of PU presented with stomal stenosis being managed by a suprapubic catheter. PU was first performed 6 years ago but he developed stomal stenosis for which a revision PU was performed. Because of recurrent stomal stenosis, and failed stomal dilatations, the patient was managed with a suprapubic catheter (SPC). On examination, lichen sclerosus changes were present at the external urethral meatus and the scrotum was normal. Two sites of stenosed PU stoma and multiple perineal incisions suggesting previous Blandy flap operations were seen. Retrograde urethrogram (RGU) was performed through the external urethral meatus [Figure 1]a and stenosed PU stoma [Figure 1]b suggesting normal membranous urethra with SPC in situ. After taking consent for surgery and routine preoperative evaluation, the patient was posted for revision PU. As he had undergone multiple flap procedures in the past, further flap procedures were deferred and TWSD was performed. | Figure 1: (a) Retrograde urethrogram through the external urethral meatus. (b) Retrograde urethrogram through the stenosed perineal urethrostomy stoma
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Turner-Warwick scrotal drop back procedure – surgical technique
Under spinal anesthesia through a vertical incision over the scarred perineum [Figure 2]a, the urethra was exposed and the healthy proximal end of the urethra was identified by passing a sound antegrade. Proximal urethral end was dissected and the mucosa was everted and sutured to the corporal bodies [Figure 2]b. Several sutures were then taken all around the urethral end with 4–0 vicryl. Scrotal skin was invaginated toward the opened urethra, and an incision was made in the anterior part of posterior scrotal skin equal to the length of the opened urethra. Urethral sutures were then brought out of the scrotal incision and were taken through the scrotal skin at all the corresponding points [Figure 2]c. All the sutures were then tied sequentially to keep the scrotal opening apposed with the urethral opening resulting in a well-fixed mucocutaneous junction. An 18 F Foley catheter was then passed per urethra. The remaining opening in the perineum and the scrotum was closed in transverse fashion after placing a drain [Figure 2]d. | Figure 2: (a) Preoperative photograph showing stenosed perineal urethrostomy stoma with multiple scars. (b) Proximal urethral end-mucosa everted and sutured. (c) Urethral sutures followed by scrotal sutures after posterior mobilization of scrotum. (d) Final appearance after closing the defect in perineum
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The patient was discharged on the 4th postoperative day after removing the drain and per urethral Foley catheter. He was advised urethral calibration once every 3 months for the 1st year after surgery and annually thereafter. At 6 months follow up, he was voiding well but had developed redness and excoriation of the peri-stomal scrotal skin for which skin care was advised.
| Discussion | | |
PU stomal stenosis is a common problem and is seen in 10%–30% of the cases. The possible reasons for the failure are recurrent disease and poor vascularity of the urethra, or of the local skin flaps.[1] Management options for patients with PU stomal stenosis include dilatation, buccal mucosal augmentation of stoma, PU revision, and continent catheterizable stoma.[1],[2] Most commonly accepted and versatile procedure is the Blandy flap PU, and the other varieties include Johanson technique, 7-flap PU, TWSD, and lotus petal flap PU.[3],[4] All the mentioned techniques have their own advantages in different clinical situations. However, during the revision PU, the skin flap viability is questionable because of the previous surgery and dissection, and sometimes, flap may not reach the urethra and cause wound dehiscence. For revision of PU meshed split-thickness graft, buccal mucosal augmentation of stoma and perforator-based lotus petal flaps have been reported in the literature.[1],[2],[4] Preoperative assessment of the posterior urethra can be performed by RGU, voiding cystourethrogram (VCUG), or antegrade cystoscopy. In the present case, RGU was performed, but VCUG would have better as the patient was on SPC. TWSD has been described in the literature as a surgical procedure for primary PU, but is uncommonly utilized. However, it is very useful in patients requiring revision PU and in cases of PU following previous multiple perineal surgeries where the blood supply of the flap is questionable. Kulkarni et al. managed complex pelvic fracture urethral injury with ischemic bulbar urethral necrosis by TWSD in three patients and reported success in one.[5] A common problem with TWSD is eczematous reaction of the scrotal skin due to urinary alkaline dermatitis. Even with good surgical technique, it is inevitable to have cross synechial adhesions and stenosis that require dilatation. Hence, our patient was postoperatively advised urethral calibration once every 3 months for the 1st year of surgery and annually thereafter.
| Conclusion | | |
TWSD is a viable option for revision PU.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lumen N, Houtmeyers P, Monstrey S, Spinoit AF, Oosterlinck W, Hoebeke P, et al. Revision of perineal urethrostomy using a meshed split-thickness skin graft. Case Rep Nephrol Urol 2014;4:12-7.  |
| 2. | Kamat N. Perineal urethrostomy stenosis repair with buccal mucosa: Description of technique and report of four cases. Urology 2008;72:1153-5. |
| 3. | Lumen N, Beysens M, Van Praet C, Decaestecker K, Spinoit AF, Hoebeke P, et al. Perineal urethrostomy: Surgical and functional evaluation of two techniques. Biomed Res Int 2015;2015:365715. |
| 4. | Reilly D, Sham E, Chee J, Chauhan A. Novel application of the lotus petal flap in high-risk perineal urethrostomy: principles and outcomes. Australas J Plast Surg 2018;1. Available from: https://www.ajops.com/index.php/ajops/article/view/17. [Last accessed on 2018 Nov 14]. |
| 5. | Kulkarni SB, Joshi PM, Hunter C, Surana S, Shahrour W, Alhajeri F, et al. Complex posterior urethral injury. Arab J Urol 2015;13:43-52. |
[Figure 1], [Figure 2]
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