- Email: [email protected]
Free Full Thickness Skin Graft Urethroplasty: Current Technique
0022-534 7/79/1213-0282$02. 00/0 Vol. 121, March Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
FREE FULL THICKNESS SKIN GRAFT URETHROPLASTY: CURRENT TECHNIQUE PATRICK C. DEVINE, JAMES R. WENDELKEN*
AND
CHARLES J. DEVINE, JR.
From the Department of Urology, Eastern Virginia Medical School, Medical Center Hospitals, DePaul Hospital and Children's Hospital of the Kings Daughters, Norfolk, Virginia
ABSTRACT
We present details of our current techniques for skin graft urethroplasty. We believe that careful attention to the details of these operative techniques is important to their success. The changes from our previous reports include: 1) preparation of patch grafts with rounded ends, 2) preparation of tube grafts with fishmouth spatulation, 3) fixation of the stent catheter to the anterior abdominal wall, 4) leaving a stent catheter inlying for 2 weeks and replacing with a smaller catheter if a voiding cystourethrogram shows extravasation, 5) fixation of the graft during preparation by dermatome adhesive, 6) irrigation of the wound with irrigant before closure and 7) urodynamic flow study for non-invasive postoperative followup. We have used free full thickness skin grafts to repair urethral strictures successfully since 1961.1-4 The principles of our technique and the details we have found necessary to change since our previous reports are reviewed. We will make no attempt to describe each of the modifications we have rejected over the years. We recommend that you try the procedure unaltered lest you use one of the unsuccessful modifications we have abandoned. Full thickness, hairless skin is the ideal material for repair or replacement of the human urethra. It can be applied to the urethra as flaps or as free grafts. The donor site for skin to be applied to the proximal urethra by the flap techniques is limited to the skin of the adjacent scrotum or perineum because of the length of the necessary vascular pedicles.5-,) The use of free full thickness autografts is the most straightforward method of application of hairless skin to the urethra. After more than 25 years of experience with these grafts in the repair of hypospadias and strictures we can assure you that they work. When properly prepared and handled free full thickness skin grafts are promptly revascularized from the underlying tissues and, when mature, attach firmly to the surrounding normal urethra and grow normally with little contracture. 6 Any diseased segment of the urethra can be exposed by 1 of 2 incisions: 1) a circumcising incision at the coronal sulcus with retraction of the penile skin as a sleeve to expose the pendulous urethra or 2) an inverted Y incision in the perineum to expose the bulbomembranous or prostatic urethra (fig. 1). We apply skin grafts to the urethra by 3 basic techniques. Patch graft. The strictured segment of urethra is incised throughout the length of the stricture and into normal urethra for at least 1 to 1½ cm. proximally and distally. A patch graft of free full thickness skin is approximated to the margins of the combined urethra and corpus spongiosum with interrupted and continuous fine absorbable suture material with the epithelial surface of the full thickness skin graft toward the lumen of the urethra. The skin graft is prepared so that the ends are rounded rather than pointed to obviate recurrent strictures at the proximal and distal ends of the patch graft. There is no limit to the length of a single patch graft or to the number of patch grafts that can be applied in a single operation (fig. 2). Accepted for publication June 30, 1978. Read at annual meeting of American Urological Association, Washington, D. C., May 21-25, 1978. * Current address: 1211 N. Shartell, #208, Oklahoma City, Oklahoma 73103. 282
B FIG. 1. Incisions. A, circumcised incision. B, perineal incision
A
B
FIG. 2. Patch graft technique. A, urethral stricture is incised. B, free, thickness skin graft with rounded apices is sutured in place.
Tube graft. A tube graft of free, full thickness, hairless skin is prepared with the epithelial surface toward the lumen. It is approximated to the urethra with interrupted and continuous
283
FREE FULL THICKNESS SKIN GRAFT URETHROPLASTY
A
B S·lf!
FIG. 3. Tube graft technique. A, reconstruction of severely scarr~d, extensive strictures requires tube graft. Diseased segment of urethra is excised and tube graft is fashioned. B, anastomosis is completed m fishmouth spatulated manner.
fine absorbable sutures with a fishmouth type spatulation of the graft and the normal urethra at each end to avoid secondary strictures owing to contracture (fig. 3). Excision and patch graft. When a short segment of urethra is so scarred that it is unsuitable for a patch graft that segment may be excised. After mobilization proximally and distally the urethra is reapproximated on its dorsal surface without tension, using interrupted fine absorbable sutures so placed that the knots are outside of the lumen of the urethra. An incision is made for 1 to 11/z cm. proximally and distally into normal urethra and a patch graft is approximated to the normal urethra with interrupted and continuous sutures of fine absorbable material (fig. 4). There occasionally are extremely complicated deep strictures of the prostatomembranous urethra that require modifications of technique but the continuity of the urethra can be re-established in even the most difficult cases by proper application of the principles of free full thickness skin graft urethroplasty (fig. 5). The successful application of these methods of skin graft urethroplasty requires careful attention to all details during the preoperative, operative and postoperative phases of the procedures. PREOPERATIVE EVALUATION
The urethra should not have been dilated for at least 6 weeks before the operation. In addition to a complete history and physical examination and evaluation of the urinary system, a complete urethrogram must be made showing the entire urethra so that all diseased segments can be identified. A urine culture and sensitivity should be obtained and appropriate antibacterial therapy should be instituted preoperatively. A urodynamic flow study is made as a preoperative base line. OPERATIVE TREATMENT
The position of the patient on the operating table must allow exposure of all diseased segments of the urethra. The lithotomy position is suitable for treatment of strictures of the pendulous urethra but when the bulbomembranous and prostatic urethra are involved the exaggerated perineal position is mandatory for adequate exposure. We have found the Vac
A
B
' C
D
C:~1~~(( /.~
FIG. 4. Excision and patch graft technique. A, urethral stricture is opened. B, diseased segment is excised. C, urethra is reapproximated dorsally. D, patch graft is anastomosed to urethral defect.
Pac* pad helpful in positioning patients. Survival of the full thickness skin graft requires 1) removal of fat from the dermal surface, 2) adequate vascularization in the host bed of the graft, 3) adequate fixation and immobilization of the graft and 4) a non-infected host bed for the graft. 1 Intraurethral instil-
* Vac Pac, Olympic Medical Corp., 4400 7th Ave. South, Seattle, Washington 98108.
284
DEVINE, WENDELKEN AND DEVINE
A
B
Fm. 5. Prostatomembranous urethral stricture. A, stricture is excised and tube graft is fashioned. B, anastomosis is completed
leaving a full thickness skin graft consisting of dermis and epidermis. This graft is cut to fit the defect or defects in the urethra and precisely approximated with interrupted and continuous sutures of fine absorbable suture material, using a silicone catheter as a stent. The wound is flushed carefully with neomycin sulfate/polymyxin B solutiont before the wound is closed. The stent catheter is attached to the abdomen to immobilize the grafted area (fig. 6). The penis is the ideal donor site and, when necessary, large amounts of penile skin can be removed to furnish enough material for long tube grafts of the perineal urethra. The shaft of the penis can then be recovered with split thickness skin grafts. These grafts will, of course, not support an underlying full thickness skin graft to repair the penile urethra. POSTOPERATIVE MANAGEMENT
The stent catheter is left inlying for 2 weeks postoperatively. A urethrogram is made at the time of catheter removal and if there is leakage from the suture line a smaller catheter is placed and left for an additional 2 weeks because it is likely that periurethral urinary extravasation can contribute to recurrent stricture formation. 9• 10 A urethrogram, urodynamic flow study and urine culture are made in 6 weeks. A repeat flow study is made in 3 months and a repeat urethrogram and flow study are made in 6 months. Periodic flow studies are sufficient to follow the patients after the initial 6 months. REFERENCES
1. Devine, P. C., Devine, C. J., Jr. and Horton, C. E.: Anterior
Fm. 6. Catheter is secured to anterior abdominal wall
lation of 1 per cent methylene blue facilitates identification of the strictured urethra. One-half per cent lidocaine with 1/100,000 epinephrine is instilled into the corpus spongiosum before the urethral incision in traumatic stricture. If the bleeding is brisk a continuous suture combining the corpus spongiosum and urethral wall is placed. The graft material should be soft, pliable hairless skin and it must be carefully prepared and handled. The graft can be stabilized by fixing it to the bottom of a sterile basin with dermatome adhesive,* allowing the subcutaneous tissue to be removed sharply and * Padget Dermatome Tape, Padget Instruments, 2838 Warwick TRFWY., Kansas City, Missouri 64108.
2. 3.
4. 5.
urethral injuries: secondary reconstruction. Urol. Clin. N. Amer., 4: 157, 1977. Devine, P. C., Fallon, B. and Devine, C. J., Jr.: Free full thickness skin graft urethroplasty. J. Urol., 116: 444, 1976. Devine, P. C., Horton, C. E., Devine, C. J., Sr., Devine, C. J., Jr., Crawford, H. H. and Adamson, J.E.: Use offull thickness skin grafts in repair of urethral strictures. J. Urol., 90: 67, 1963. Devine, P. C., Sakati, I. A., Poutasse, E. F. and Devine, C. J., Jr.: One stage urethroplasty: repair of urethral strictures with a free full thickness patch of skin. J. Urol., 99: 191, 1968. Converse, J.M., McCarthy, J. G., Brauer, R. 0. and Ballantyne, D. L., Jr.: Transplantation of skin: grafts and flaps. In:
t Neosporin G.U. Irrigant, 1 ampule diluted to 500 cc with sterile saline, Burroughs Wellcome Co., Research Triangle Park, North Carolina.
FREE FULL THICKNESS SKIN GRAFT URETHROPLASTY
285
Reconstructive Plastic Surgery. Edited by J. M. Converse. Acta Chir. Scand., suppl. 176, 1953. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 6., pp. 152- 8. Leadbetter, G. W., Jr.: A simplified urethroplasty for strictures 239, 1977. of the bulbous urethra. J. Urol., 83: 54, 1960. 6. Gil-Vernet, J. M.: Un traitement des stenoses traumatique et 9. Turner-Warwick, R. T.: A technique for posterior urethroplasty. inflammatoires de l'uretre posterieur. Nouvelle methode J. Urol., 83: 416, 1960. d'uretroplastie. J. Urol. Nephrol., 72: 97, 1966. 10. Singh, M. and Blandy, J.P.: The pathology of urethral stricture. 7. Johanson, B.: Reconstruction of the male urethra in strictures. J. Urol., 115: 673, 1976.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
FREE FULL THICKNESS SKIN GRAFT URETHROPLASTY: CURRENT TECHNIQUE PATRICK C. DEVINE, JAMES R. WENDELKEN*
AND
CHARLES J. DEVINE, JR.
From the Department of Urology, Eastern Virginia Medical School, Medical Center Hospitals, DePaul Hospital and Children's Hospital of the Kings Daughters, Norfolk, Virginia
ABSTRACT
We present details of our current techniques for skin graft urethroplasty. We believe that careful attention to the details of these operative techniques is important to their success. The changes from our previous reports include: 1) preparation of patch grafts with rounded ends, 2) preparation of tube grafts with fishmouth spatulation, 3) fixation of the stent catheter to the anterior abdominal wall, 4) leaving a stent catheter inlying for 2 weeks and replacing with a smaller catheter if a voiding cystourethrogram shows extravasation, 5) fixation of the graft during preparation by dermatome adhesive, 6) irrigation of the wound with irrigant before closure and 7) urodynamic flow study for non-invasive postoperative followup. We have used free full thickness skin grafts to repair urethral strictures successfully since 1961.1-4 The principles of our technique and the details we have found necessary to change since our previous reports are reviewed. We will make no attempt to describe each of the modifications we have rejected over the years. We recommend that you try the procedure unaltered lest you use one of the unsuccessful modifications we have abandoned. Full thickness, hairless skin is the ideal material for repair or replacement of the human urethra. It can be applied to the urethra as flaps or as free grafts. The donor site for skin to be applied to the proximal urethra by the flap techniques is limited to the skin of the adjacent scrotum or perineum because of the length of the necessary vascular pedicles.5-,) The use of free full thickness autografts is the most straightforward method of application of hairless skin to the urethra. After more than 25 years of experience with these grafts in the repair of hypospadias and strictures we can assure you that they work. When properly prepared and handled free full thickness skin grafts are promptly revascularized from the underlying tissues and, when mature, attach firmly to the surrounding normal urethra and grow normally with little contracture. 6 Any diseased segment of the urethra can be exposed by 1 of 2 incisions: 1) a circumcising incision at the coronal sulcus with retraction of the penile skin as a sleeve to expose the pendulous urethra or 2) an inverted Y incision in the perineum to expose the bulbomembranous or prostatic urethra (fig. 1). We apply skin grafts to the urethra by 3 basic techniques. Patch graft. The strictured segment of urethra is incised throughout the length of the stricture and into normal urethra for at least 1 to 1½ cm. proximally and distally. A patch graft of free full thickness skin is approximated to the margins of the combined urethra and corpus spongiosum with interrupted and continuous fine absorbable suture material with the epithelial surface of the full thickness skin graft toward the lumen of the urethra. The skin graft is prepared so that the ends are rounded rather than pointed to obviate recurrent strictures at the proximal and distal ends of the patch graft. There is no limit to the length of a single patch graft or to the number of patch grafts that can be applied in a single operation (fig. 2). Accepted for publication June 30, 1978. Read at annual meeting of American Urological Association, Washington, D. C., May 21-25, 1978. * Current address: 1211 N. Shartell, #208, Oklahoma City, Oklahoma 73103. 282
B FIG. 1. Incisions. A, circumcised incision. B, perineal incision
A
B
FIG. 2. Patch graft technique. A, urethral stricture is incised. B, free, thickness skin graft with rounded apices is sutured in place.
Tube graft. A tube graft of free, full thickness, hairless skin is prepared with the epithelial surface toward the lumen. It is approximated to the urethra with interrupted and continuous
283
FREE FULL THICKNESS SKIN GRAFT URETHROPLASTY
A
B S·lf!
FIG. 3. Tube graft technique. A, reconstruction of severely scarr~d, extensive strictures requires tube graft. Diseased segment of urethra is excised and tube graft is fashioned. B, anastomosis is completed m fishmouth spatulated manner.
fine absorbable sutures with a fishmouth type spatulation of the graft and the normal urethra at each end to avoid secondary strictures owing to contracture (fig. 3). Excision and patch graft. When a short segment of urethra is so scarred that it is unsuitable for a patch graft that segment may be excised. After mobilization proximally and distally the urethra is reapproximated on its dorsal surface without tension, using interrupted fine absorbable sutures so placed that the knots are outside of the lumen of the urethra. An incision is made for 1 to 11/z cm. proximally and distally into normal urethra and a patch graft is approximated to the normal urethra with interrupted and continuous sutures of fine absorbable material (fig. 4). There occasionally are extremely complicated deep strictures of the prostatomembranous urethra that require modifications of technique but the continuity of the urethra can be re-established in even the most difficult cases by proper application of the principles of free full thickness skin graft urethroplasty (fig. 5). The successful application of these methods of skin graft urethroplasty requires careful attention to all details during the preoperative, operative and postoperative phases of the procedures. PREOPERATIVE EVALUATION
The urethra should not have been dilated for at least 6 weeks before the operation. In addition to a complete history and physical examination and evaluation of the urinary system, a complete urethrogram must be made showing the entire urethra so that all diseased segments can be identified. A urine culture and sensitivity should be obtained and appropriate antibacterial therapy should be instituted preoperatively. A urodynamic flow study is made as a preoperative base line. OPERATIVE TREATMENT
The position of the patient on the operating table must allow exposure of all diseased segments of the urethra. The lithotomy position is suitable for treatment of strictures of the pendulous urethra but when the bulbomembranous and prostatic urethra are involved the exaggerated perineal position is mandatory for adequate exposure. We have found the Vac
A
B
' C
D
C:~1~~(( /.~
FIG. 4. Excision and patch graft technique. A, urethral stricture is opened. B, diseased segment is excised. C, urethra is reapproximated dorsally. D, patch graft is anastomosed to urethral defect.
Pac* pad helpful in positioning patients. Survival of the full thickness skin graft requires 1) removal of fat from the dermal surface, 2) adequate vascularization in the host bed of the graft, 3) adequate fixation and immobilization of the graft and 4) a non-infected host bed for the graft. 1 Intraurethral instil-
* Vac Pac, Olympic Medical Corp., 4400 7th Ave. South, Seattle, Washington 98108.
284
DEVINE, WENDELKEN AND DEVINE
A
B
Fm. 5. Prostatomembranous urethral stricture. A, stricture is excised and tube graft is fashioned. B, anastomosis is completed
leaving a full thickness skin graft consisting of dermis and epidermis. This graft is cut to fit the defect or defects in the urethra and precisely approximated with interrupted and continuous sutures of fine absorbable suture material, using a silicone catheter as a stent. The wound is flushed carefully with neomycin sulfate/polymyxin B solutiont before the wound is closed. The stent catheter is attached to the abdomen to immobilize the grafted area (fig. 6). The penis is the ideal donor site and, when necessary, large amounts of penile skin can be removed to furnish enough material for long tube grafts of the perineal urethra. The shaft of the penis can then be recovered with split thickness skin grafts. These grafts will, of course, not support an underlying full thickness skin graft to repair the penile urethra. POSTOPERATIVE MANAGEMENT
The stent catheter is left inlying for 2 weeks postoperatively. A urethrogram is made at the time of catheter removal and if there is leakage from the suture line a smaller catheter is placed and left for an additional 2 weeks because it is likely that periurethral urinary extravasation can contribute to recurrent stricture formation. 9• 10 A urethrogram, urodynamic flow study and urine culture are made in 6 weeks. A repeat flow study is made in 3 months and a repeat urethrogram and flow study are made in 6 months. Periodic flow studies are sufficient to follow the patients after the initial 6 months. REFERENCES
1. Devine, P. C., Devine, C. J., Jr. and Horton, C. E.: Anterior
Fm. 6. Catheter is secured to anterior abdominal wall
lation of 1 per cent methylene blue facilitates identification of the strictured urethra. One-half per cent lidocaine with 1/100,000 epinephrine is instilled into the corpus spongiosum before the urethral incision in traumatic stricture. If the bleeding is brisk a continuous suture combining the corpus spongiosum and urethral wall is placed. The graft material should be soft, pliable hairless skin and it must be carefully prepared and handled. The graft can be stabilized by fixing it to the bottom of a sterile basin with dermatome adhesive,* allowing the subcutaneous tissue to be removed sharply and * Padget Dermatome Tape, Padget Instruments, 2838 Warwick TRFWY., Kansas City, Missouri 64108.
2. 3.
4. 5.
urethral injuries: secondary reconstruction. Urol. Clin. N. Amer., 4: 157, 1977. Devine, P. C., Fallon, B. and Devine, C. J., Jr.: Free full thickness skin graft urethroplasty. J. Urol., 116: 444, 1976. Devine, P. C., Horton, C. E., Devine, C. J., Sr., Devine, C. J., Jr., Crawford, H. H. and Adamson, J.E.: Use offull thickness skin grafts in repair of urethral strictures. J. Urol., 90: 67, 1963. Devine, P. C., Sakati, I. A., Poutasse, E. F. and Devine, C. J., Jr.: One stage urethroplasty: repair of urethral strictures with a free full thickness patch of skin. J. Urol., 99: 191, 1968. Converse, J.M., McCarthy, J. G., Brauer, R. 0. and Ballantyne, D. L., Jr.: Transplantation of skin: grafts and flaps. In:
t Neosporin G.U. Irrigant, 1 ampule diluted to 500 cc with sterile saline, Burroughs Wellcome Co., Research Triangle Park, North Carolina.
FREE FULL THICKNESS SKIN GRAFT URETHROPLASTY
285
Reconstructive Plastic Surgery. Edited by J. M. Converse. Acta Chir. Scand., suppl. 176, 1953. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 6., pp. 152- 8. Leadbetter, G. W., Jr.: A simplified urethroplasty for strictures 239, 1977. of the bulbous urethra. J. Urol., 83: 54, 1960. 6. Gil-Vernet, J. M.: Un traitement des stenoses traumatique et 9. Turner-Warwick, R. T.: A technique for posterior urethroplasty. inflammatoires de l'uretre posterieur. Nouvelle methode J. Urol., 83: 416, 1960. d'uretroplastie. J. Urol. Nephrol., 72: 97, 1966. 10. Singh, M. and Blandy, J.P.: The pathology of urethral stricture. 7. Johanson, B.: Reconstruction of the male urethra in strictures. J. Urol., 115: 673, 1976.