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cUrrEnt concEPts of antErior UrEthral Pathology: ManagEMEnt and fUtUrE dirEctions

urethral stricture ranging between 1 and 3 cm in length.Above this length a substitution procedure is more likely. The etiology of a stricture has an influence on any decision since inflammatory strictures and those associated with BXO have a tendency to be longer and in the context of the latter have a tendency to recurrence because of recrudescence of the underlying disease process.

Preoperatively, one must warn the patient about the risks of the procedure mentioning; complications, failure rate, need for additional procedures, need for follow-up, and recurrence. Much is publicized about the risk of erectile dysfunction and three papers have appeared in the literature over the last decade relating to this. Coursey et al. reported in a retrospective study that in experienced hands most men who undergo anterior urethral reconstruction are no more likely to have impaired sexual function than those that undergo circumcision.21 Clearly, alterations in the penile appearance and sexual performance may occur after anterior urethroplasty,which are usually transient and more likely if the stricture is lengthy,than if it is a short stricture requiring an anastomotic procedure. Anger and colleagues supported this view suggesting that surgery had an insignificant long-term effect on erectile dysfunction and that surgical complexity made no difference to the incidences of erectile dysfunction.22 Erickson and colleagues (2006) confirmed these findings, both papers however suggesting clearly that there was an increasing risk of erectile dysfunction with increasing age and if there was a preceding history of problems.23 A prospective study has recently been reported suggesting that there is a risk of erectile dysfunction within the first few months following surgery,24 which certainly equates with our personal experience, but with time this improves and most men who develop erectile dysfunction of any sort will have full recovery by 7 months. They did note that in some men, persistence of erectile dysfunction was seen,but that long-term follow-up would be necessary before they can categorically provide advice based on this information.

Urethroplasty

The length of a urethral stricture will dictate the complexity of the necessary surgery; longer lesions require more complicated surgery. The spectrum of “urethroplasty” surgery employs the full armamentarium of plastic surgical skills. Ranging from the simplest procedure for

short strictures, an anastomotic urethroplasty, where the diseased urethral segment is excised and the two ends anastomosed together; up to a substitution urethroplasty where a longer segment of urethral lumen is replaced by a graft or flap using a oneor two-stage technique. In this chapter we will give an overview of the different techniques in practice and review the evidence base relating to their use.

Anastomotic Urethroplasty

Anastomotic urethroplasty involves excision of the stricture and primary anastomosis of the urethral ends. Traditionally, strictures less than 3 cm only were considered suitable for an anastomotic procedure. However, by freeing up the urethra and separating the corpora (Fig. 31.2a) another few centimeters may be gained in length. Morey et al. when comparing anastomotic procedures carried out for a stricture length ranging from 2.6 to 5.0 cm reported success rates of 91%, as compared to a control group with a stricture length less than 2.5 cm. However, the series only had 11 patients in each group and the mean fol- low-up period was 22 months.25 Two large series have recently been reported looking at the success rates of anastomotic urethroplasty – Santucci et al. (2002)26 and Barbagli et al. (2008),27 reporting success rates of 95% and 91%, respectively.

The procedure for anastomotic urethroplasty is detailed below: When tackling a bulbar stricture which is one of the commonest types of stricture, a midline skin incision is made in the perineum behind the scrotum.Following dissection through the superficial tissues, the bulbospongiosus muscle is exposed (Fig. 31.2b, c). Division of the bulbospongiosus muscle has been criticized recently by Barbagli et al. who describe a procedure used in 12 patients with bulbar urethral strictures where dissection of the bulbospongiosus muscle off of the corpus spongiosum was avoided, leaving the central tendon of the perineum intact.28 The majority of surgeons do not feel that it is necessary to preserve the integrity of this muscle and there is only limited expert opinion suggesting that this approach is beneficial.

Thereafter, the next step is to dissect behind the urethra between the corpus spongiosum and the corpora cavernosa, thus freeing the urethra completely (Fig. 31.2d, e). It is important to identify the exact site of the stricture, either using a sound, or as we prefer to do this using an

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endoscope to precisely identify the stricture,		minimizing the potential for converting an anas-
transilluminate its distal end with the cystoscope		tomotic procedure into a substitution procedure
and then put a stitch directly through at the dis-		by reducing the length of the incised urethra.
tal extent of the stricture. By cutting just proxi-		In carrying out the anastomotic procedure it is
mal to the suture which is placed in the stricture,		important to spatulate the urethra extending the
it is possible to transect the urethra accurately		incision into normal tissue at both ends and to fix
without any loss of normal urethra, therefore		the proximal urethra by sutures that pass through
a	b	c

1	2	3
		6
1		5
2
	3	4
d		e	f

Figure 31.2. (a) diagrammatic representation of the additional length gained by separation of the corpora cavernosa. numbers represent approximate length in centimeters (Mundy, BJUi surgical atlas) (b, c) Midline perineal incision, through the superficial tissues exposing and dividing the bulbospongiosus muscle to expose the urethra (reprinted from Mundy ar, Urodynamic and Reconstructive Surgery of the Lower Urinary Tract. copyright Elsevier, 1993) (d, e) completely freeing the urethra from the corpora cavernosa (reprinted from Mundy ar, Urodynamic and Reconstructive Surgery of the Lower Urinary Tract. copyright Elsevier,

1993) (f, g) spatulating both ends of the urethra to aid anastomosis.chapple pic,Mundy figure (g – reprinted from Mundy ar,

Urodynamic and Reconstructive Surgery of the Lower Urinary Tract. copyright Elsevier, 1993) (h, i) completion of the anastomosis, note rotation of the distal urethra by 180° (i – reprinted from Mundy ar, Urodynamic and Reconstructive Surgery of the Lower Urinary Tract. copyright Elsevier, 1993) (j) closure of the corpora cavernosa over the bulbar urethral anastomosis (reprinted from Mundy ar, Urodynamic and Reconstructive Surgery of the Lower Urinary Tract. copyright Elsevier, 1993).

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Figure 31.2. (continued)	g	h

i

j

the full thickness of the corpus spongiosum into the tunica albuginea of the corpora cavernosa thereby avoiding contracture at the site of the anastomosis (Fig. 31.2f, g). We usually use a size 32 F sound to check this easily passes through the anastomosis prior to closure. It is also important to bear in mind that one can rotate the distal urethra through 180° to achieve the optimal positioning of the spatulated ends during the subsequent anastomosis (Fig. 31.2h, i).

When closing the urethra we usually use a two-layer anastomosis ventrally, the outer layer should be a running suture as this is important to secure hemostasis of the corpus spongiosum. Careful closure of subcutaneous tissue planes is important to adequately occlude dead space and prevent either hematoma formation or infection from occurring; in our experience using this approach followed by a firm supporting dressing using elasticated

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	knickers for 4 days is important as it prevents				substitution – a so-called onlay substitution pro-
	hematoma formation. We tend to leave both a				cedure, or the third option that we would not
	urethral and a suprapubic catheter for 12–14 days				recommend is to excise the stricture and put in a
	followed by a contrast study to check that the				circumferential patch – a tube substitution. This
	anastomosis is “watertight.” This is followed				latter option is associated with a high failure rate,
	by removal of the urethral catheter which is in				which may be as high as 30%.29,30 A two-stage
	turn followed by removal of the suprapubic				procedure involves excision of the stricture and
	catheter.				the abnormal urethra and reconstruction of a
	It is often possible to carry out an anastomotic				roof strip which is allowed to heal prior to sec-
	urethroplasty for strictures longer than 2–3 cm.				ond-stage tubularization.
	Foreshortening of the urethral course by sepa-
	rating the two bodies of the corpora cavernosa				Grafts Versus Flaps
	is an important maneuver since it will lead to
	straightening of the natural curve of the bulbar				Prior controversy existed in the field relating to
	urethra and allow an additional 2–4 cm in length
					whether one should use a graft or flap, but it is
	depending on local circumstances (Fig. 31.2a).
					now clearly established from a review of the lit-
	Closure of the urethra can then be accomplished
					erature that the re-stenosis rate recorded in the
	in a standard fashion. The corpora cavernosa
					published literature in 1998 was between 14.5%
	can be closed over the bulbar urethral anasto-
					and 15.7% using either a flap or graft, respec-
	mosis (Fig. 31.2l). Clearly, the amount of length
					tively.31 It can therefore be concluded that there
	that can be gained will		depend upon	the
					is no advantage of a graft over a flap in terms of
	anatomical circumstances		depending on	the
					re-stenosis rate. Indeed Dubey in a small com-
	anatomy of any individual male and this is pro-
					parative randomized study confirmed there to
	portional to the length and the elasticity of the
					be equivalence in terms of success with the two
	distal urethral segment, and in particular the
					techniques but with higher morbidity for the
	size of the penis and urethra itself. As we men-
					patients using a flap procedure.32
	tioned earlier, it is now clearly established that
					In carrying out a substitution procedure, one
	anastomotic urethroplasty in the bulbar urethra
					has to also consider whether full thickness tis-
	in experienced hands is associated with a suc-
					sue or partial thickness tissue is used. The
	cess rate of up to 95%.26,27
					importance of this is that partial thickness tis-
					sue has a greater propensity to contract than full
	Substitution Urethroplasty				thickness tissue.
					The number of therapeutic options which
	The factors limiting the potential for using anas-				have been suggested in the past include scrotal
	tomotic urethroplasty are the length of the stric-				skin,33 extragenital skin,34 bladder mucosa,35
	ture and anatomical considerations. One cannot				and colonic mucosa.36 In contemporary prac-
	simply excise a stricture and restore continuity				tice, genital skin or oral mucosa are most com-
	as in the gut, because of the potential for causing				monly used, although there is interest in the
	a chordee; in fact, it is a useful rule that the bul-				future in the potential for tissue engineering.37
	bar urethra should not be mobilized distal to the				Genital skin flaps are particularly useful when
	penoscrotal junction and therefore if the stric-				dealing with strictures in the penile urethra
	ture is lengthy it may be necessary to carry out a				where an onlay flap of penile skin can be par-
	substitution procedure. Similarly, it is very				ticularly helpful. However, bear in mind that the
	uncommon except in the context of a very lim-				use of penile skin in this context is contraindi-
	ited traumatic injury of the penile urethra such				cated if there is any suggestion that BXO is pres-
	as seen with penile rupture injuries to be able to				ent which tends to recur in skin (either genital
	carry out an anastomotic urethroplasty in the				or extragenital in origin). Furthermore, Blandy
	penile urethra. A substitution procedure could				et al. found a scrotal pull through procedure to
	be either a one-stage or a two-stage procedure.				have a high incidence of complications38 and to
	There are three potential options with a one-				his credit at the end of his career reported on the
	stage procedure; to excise the stricture and				significant morbidity, in the longer term, associ-
	restore a roof strip of native urethra augmented				ated with the use of scrotal skin. Scrotal skin in
	by a patch – an augmented anastomotic proce-				our view should not be used except in excep-
	dure, to incise the stricture and carry out a patch				tional circumstances.

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A number of different types of flap have been described over the years and these vary in terms of their orientation and whether they have bilateral or unilateral pedicles (Fig. 31.3a–d).A number of eponymous names based on the authors who reported them have been utilized to describe the contemporary flaps which are recognized. We would suggest a more pragmatic approach. When considering a flap, firstly identify an area of hairless penile skin (it is important not to allow the patient to be shaved before coming to the operating room) of adequate length to reconstruct the urethral defect. Next,

based on the anatomy of the penis, decide the configuration of the flap, that is, transverse, longitudinal, oblique, etc. Next, determine how to obtain adequate subcutaneous tissue –using a bilateral or unilateral pedicle. Remember that the skin is a “passenger” on the subcutaneous tissues. Ventral onlay skin flaps are particularly useful in the management of penile strictures due to etiologies other than BXO.

When considering the bulbar urethra, the current recognized standard of care is to use a graft in the majority of cases, since the efficacy of grafts and flaps appears to be very similar.39

a

b

c

d

Figure 31.3. (a–d) Various flaps utilized in urethroplasty.

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		Practical Urology: EssEntial PrinciPlEs and PracticE
A randomized controlled trial carried out by		(Fig. 31.4a), skin necrosis (Fig. 31.4b), fistula
Dubey, showed that the efficacy of both grafts		formation (Fig. 31.4c), and if one is using a dis-
and flaps was identical, but there was a much		tal flap derived from the prepuce, penile and
higher morbidity with penile skin flaps which		glans torsion (Fig. 31.4d). In the longer term,
were also technically more complex and less		flaps are associated with a higher propensity to
likely to be preferred by patients because of the		sacculation formation in the substitution
morbidity.32 Indeed it is well recognized that a		(Fig. 31.4e, f).
number of complications can occur following		Barbagli and colleagues have reviewed their
flap urethroplasty including penile hematoma		experience using dorsal onlay skin graft
	a	b

c

d

e

f

Figure 31.4. (a–f) complications of flap urethroplasty. (a) hematoma, (b) skin necrosis, (c) fistula, (d) glans torsion, (e, f) sacculation. (a–d – courtesy of guido Barbagli).