Year : 2001 | Volume
: 17 | Issue : 2 | Page : 145--151
Single stage reconstruction of complex anterior urethral strictures
Deepak Dubey, Aneesh Srivastava, Rakesh Kapoor, Anant Kumar, Mahendra Bhandari, Anil Mandhani
Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Department of Urology, SGPGIMS, Lucknow - 226 014
Purpose: Single stage reconstruction of long, complex urethral strictures is technically demanding and may require the use of more than one tissue transfer technique. We describe our experience in the management of such strictures with a variety of urethroplasty techniques.
Materials and Methods: Between 1989 and 1999, 25 men (mean age 38.5 years) underwent single stage reconstruction of panurethral, multiple segment or focally dense strictures [mean length 11.2 cm (range 8-17 cm)]. 8 patients had combined substitution urethroplasty with a circumpenile fasciocutaneous flap and a free graft of bladder/buccal mucosa or tunica vaginalis . flap. In 10 patients a single tissue transfer technique was used. 3 patients underwent an augmented roof/floor strip urethroplasty with a penile skin flap. 4 patients with multiple segment strictures (separate pendulous and bulbar) underwent distal onlay flap and proximal anastomotic urethroplasty.
Results: The median ,follow-up was 46.5 months (range 6-88 months). The mean postoperative flow rate improved to 22.5 ml/sec. 2 patients developed fistulae requiring repair. Recurrent stricture developed in 5 (20.8%) patients, of which 2 were managed with visual internal urethrotomy, 2 with anastomotic urethroplasty and 1 with a two-stage procedure. Pseudodiverticulum and post-void dribbling were seen in 6 (25%) patients.
Conclusions: Successful outcome of single stage reconstruction of long complex strictures can be achieved with a combination of various tissue transfer methods. The urologist who has a thorough knowledge of penile skin and urethral vascular anatomy and a wide array of substitution techniques in his armamentarium can undertake approach to such strictures.
|How to cite this article:|
Dubey D, Srivastava A, Kapoor R, Kumar A, Bhandari M, Mandhani A. Single stage reconstruction of complex anterior urethral strictures.Indian J Urol 2001;17:145-151
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Dubey D, Srivastava A, Kapoor R, Kumar A, Bhandari M, Mandhani A. Single stage reconstruction of complex anterior urethral strictures. Indian J Urol [serial online] 2001 [cited 2022 Aug 9 ];17:145-151
Available from: https://www.indianjurol.com/text.asp?2001/17/2/145/21045
Strictures are termed complex when they have focally dense segments, are lengthy or multiple and/or have associated deficiency of penile skin.  These strictures pose problems in management due to their length and associated spongiofibrosis and are usually an indication for a 2-staged scrotal inlay , or a staged mesh graft urethroplasty.  Staged scrotal inlays are cumbersome for patients and associated with multiple revisions,  high recurrence rates' and complications like diverticulum formation, hair growth and urethrocutaneous fistula.  Experience with meshgraft urethroplasty is limited and patients may require increased number of interventions in the interim period.  Whenever possible a single stage reconstruction is always preferable to patients. With the excellent results of buccal mucosal graft urethroplasty there has been a renewed interest in the combined use of grafts and flaps for such complex strictures. , In experienced hands a single stage procedure involving a combination of different techniques can give good results.  We share our experience in the single stage reconstruction of complex lengthy strictures with various techniques.
Patients and Methods
Between 1989 and 1999, 25 patients (mean age 38.5 years) underwent single stage substitution urethroplasty for compelx urethral strictures. Of these, 18 patients had panurethral strictures (defined as stricture involving significant portions of both pendulous and bulbar urethra)  with a mean length of 12.5 cm (range 12-14 cm), 4 had multiple segment strictures (2 separate strictures with intervening normal urethra), and 3 had long strictures with a focal area of almost destroyed urethral plate [Table 1]. The aetiology was post inflammatory,  ischaemic (following urethral catheterization),  Balanitis xerotica obliterans,  and traumatic.  All patients had a prior history of urethral intervention in the form of dilatations and/or visual internal urethrotomy. In addition 3 patients had a failed anastomotic urethroplasty performed elsewhere. 11 patients had a suprapubic cystostomy and 14 patients had a mean peak flow rate of 7.4 ml/sec. All patients were evaluated with a retrograde urethrogram and micturating cystourethrogram.
Panurethral strictures: When sufficient penile skin was available, a circular fasciocutaneous flap  was used as an onlay in strictures with a healthy salvageable urethral plate and as tube where the urethral plate was very thin or unhealthy. When penile skin was insufficient to substitute the entire stricture, a longitudinal penoscrotal-midline flap,  multiple buccal mucosal grafts or combined tissue transfer techniques were used. Combined tissue transfer was performed with a circular fasciocutaneous flap onlay on the pendulous urethra and a bladder/buccal mucosal graft or tunica vaginalis onlay flap for the bulbar urethra. Buccal and bladder mucosa were harvested using the techniques described by Morey and McAninch  and Keating et al  respectively. The flap/graft onlay was placed either ventrally or dorsally on the corporeal bodies.
Multiple segment strictures: When normal urethra intervened between 2 separate stricture segments, circular fasciocutaneous flap onlay was used for the distal (pendulous) stricture and an anastomotic urethroplasty for the proximal (bulbar) stricture.
Strictures with a focally dense urethral plate: These patients underwent an augmented roof/floor strip anastomosis with flap onlay. The urethra was dissected off the corporeal bodies following which a ventral/dorsal urethrotomy was performed. A segment of abnormal/unhealthy urethral plate (max 2 cm) was excised and re-anastomosed with interrupted sutures. Subsequently a circular fasciocutaneous flap onlay was performed [Figure 1]a and b.
Inferior pubectomy was performed to facilitate proximal placement of the flap/graft/tube in patients with high bulbar strictures. Reconstruction of associated meatal strictures (as in BXO) was performed by glans wing creation and ventral flap onlay  or dorsal flap onlay. 
Patients were followed postoperatively with uroflowmetry, urethral calibration and retrograde urethrograms at 3 months and subsequently when required.
18 patients had panurethral strictures with a mean length of 12.5 cm (range 12-14 cm). Of these 10 patients had reconstruction with a single tissue transfer technique (circular penile fasciocutaneous flap onlay  /tube,  midline penoscrotal longitudinal flap  and multiple buccal mucosa strips).  Combined tissue transfer techniques were used in 8 patients (penile flap + buccal mucosa,  penile flap + bladder mucosa,  penile flap + tunica vaginalis flap).  4 patients had an augmented roof/floor strip urethroplasty for focally dense strictures and 3 patients had a distal (pendulous) flap onlay and proximal (bulbar) anastomotic urethroplasty [Table 2].
The median follow-up period was 46.5 months (range 688 months). The mean post-operative flow rate improved to 22.5 ml/sec (range 16-31 ml/sec). Excellent postoperative outcome was achieved in 20 patients [Figure 2]a, b,[Figure 3]a, b. 3 patients with circular fasciocutaneous flap onlay developed superficial epidermal necrosis which settled on conservative management. Of the patients who had combined tissue transfer (flap and graft), 2 developed subcoronal fistulae which required closure. 5 patients developed stricture recurrence at a mean time of 22 months post-operatively. The patient who had a combination of a flap and tunica vaginalis graft developed a dense recurrent stricture (4cm) in the grafted (bulbar) segment. This patient underwent stage one of the staged scrotal inlay urethroplasty. He was happy with the outcome and refused second stage of the operation. I patient with a full circumference tube reconstruction developed recurrence at the bulbomembranous region which required anastomotic urethroplasty. 3 patients (1 with a focally dense stricture and 2 with multiple segment involvement) developed recurrences. Of these 2 were cured with visual internal urethrotomy whereas 1 patient (multiple segment stricture) required a repeat anastomotic urethroplasty for the bulbar stricture. 1 patient who had a midline longitudinal penoscrotal flap onlay developed intraluminal hair growth in the scrotal segment. Pseudo-diverticulum formation was seen in 6 patients (1 with bladder mucosa, 4 patients with a cirumpenile flap and I patient with a longitudinal penoscrotal flap) [Table 2]. Post-void dribbling was a troublesome complication in 6 patients. None of the patients reported erectile dysfunction.
Our results demonstrate that excellent outcome of single stage reconstruction for complex urethral strictures can be achieved with the appropriate use of various urethroplasty techniques. A 20% recurrence rate after a median follow-up of 46.5 months could be acceptable in patients who have had multiple previous operations. In our experience the circumpenile fasciocutaneous flap has emerged as the most versatile technique of tissue transfer for long strictures. It is hairless and can provide length up to 15 cm [Figure 4] in some patients (as was seen in 3 of our patients). It can be transferred to any part of the urethra right from the meatus till the bladder neck. Inferior pubectomy is a useful adjunct in placement of the flap more proximally in the membranous urethra. It can be combined successfully with other tissue transfer techniques  and is particularly useful for recurrent strictures.  McAninch  who initially described this flap, demonstrated its success in 66 patients with a mean stricture length of 9.06 cm.  In 4 patients with an unsalvageable urethral plate, the flap was tubularised. Of these, only 1 patient developed a recurrent stricture which was managed with an anastomotic urethroplasty. Full circumference reconstruction with both flaps and grafts provide inferior results and have been criticized. ,, In such cases a 2-stage mesh-graft urethroplasty is usually recommended.  We have found tubed reconstructions of particular value when the stricture extends up to the level of the verumontanum (as seen in .2 of our patients). In these circumstances a staged mesh graft urethroplasty would be technically difficult. 
When penile skin is insufficient or contra-indicated (as in BXO) substitution urethroplasty for long strictures can be performed using a midline longitudinal penoscrotal flap, combined flap and graft, or multiple buccal mucosal strips. 
The midline penoscrotal flap can provide length up to 12-17 cm.  However hairgrowth in the scrotal skin (as was seen in I of our patients) can be a troublesome complication. While applying combined tissue transfer techniques (flap + graft), it is essential to know the anatomy and vascular supply of the urethra. The bulbar urethra has a bulky spongiosum and receives direct blood supply from the bulbourethral artery. The distal spongiosum is less well developed and receives its blood supply from the dorsal penile artery via the glans. Thus the bulbar urethra is more reliable in terms of blood supply. Hence free grafts which rely on the vascular bed for take are best applied on the bulbar urethra.  All our patients with free grafts were onlaid onto the bulbar urethra. We initially applied grafts as a ventral onlay (bladder mucosa). With the recent excellent results of dorsal onlay graft urethroplasty , our strategy has changed to both dorsal onlay for both grafts and flaps. In our patients buccal mucosal grafts were applied dorsally on the bulbar urethra in 4 patients and 1 patient with a panurethral stricture and BXO had complete urethral substitution with 2 strips of buccal mucosa (6cm and 7cm) [Figure 3]a and b. In this patient meatal stricture reconstruction was also carried out by a dorsaal application of the buccal mucosal graft as described by Kulkarni et al.  These authors have reported excellent results in single stage reconstruction of panurethral strictures due to BXO with multiple strips of buccal mucosa. Others too have successfully treated long strictures with buccal mucosa. , Our experience with buccal mucosa has been recent and long-term results using the same are awaited.
Focally dense strictures with an unhealthy urethral plate are usually managed by converting the flap/graft into a tube at that particular area. However such situations can be managed by focal excision of 1-2 cm of the unhealthy urethral plate followed by a dorsal or ventral re-approximation of the cut ends. Subsequently tissue transfer can be made as an onlay (augmented floor/roof strip urethroplasty). 4 of our patients had this procedure and none reported any degree of penile shortening. If excision is limited to 1-2 cm of the urethral plate, penile shortening does not occur. However if the focally dense segment is > 2 cm, then the patient should be warned regarding the possibility of some penile shortening.  Guralnick et al  have recently reported excellent results using this technique in a large number of patients.
In our study recurrences were seen in patients with both combined and single tissue transfer techniques. Of these only 1 (patient with the proximal tunica vaginalis flap) had a refractory stricture. Two recurrences were successfully managed by a single visual internal urethrotomy and two with an anastomotic urethroplasty. Pseudodiverticulum fomation with resultant post-void dribbling was seen in 6 patients with ventrally applied flaps/grafts. Therefore dorsal placement of the flaps/grafts may be more appropriate.
Single stage reconstruction for long, complex anterior urethral strictures can be performed successfully with single or combined tissue transfer techniques. The circumpenile fasciocutaneous flap is the most versatile tissue transfer technique as it provides substantial length and can be successfully combined with free grafts, and other procedures like anastomotic and augmented roof/floor strip urethroplasty. In the absence of adequate penile skin or where it is contraindicated, buccal mucosa is an excellent substitute for substitution of long strictures. By preserving the urethral plate two-stage techniques can be avoided in most circumstances.
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