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One-Stage Skin Graft Urethroplasty in Anterior Middle Urethra: A New Procedure
0022-534 7/84/1314-0660$02.00/0 Vol. 131, April Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1984 by The Williams & Wilkins Co.
ONE-STAGE SKIN GRAFT URETHROPLASTY IN ANTERIOR MIDDLE URETHRA: A NEW PROCEDURE RUGGERO LENZI,* GUIDO BARBAGLI AND NICETA STOMACI From the Department of Urology, University of Florence, Florence, Italy
ABSTRACT
A new procedure with the use of a free skin patch graft for the surgical treatment of strictures located in the mid anterior urethra is described. To avoid the formation of a urethral diverticulum, the skin graft is sutured dorsally rather than ventrally and subsequently is fixed on the tunica albuginea of the corpora, which support the patch. We describe 4 different procedures according to the extent of the stenosis and the degree of involvement of the spongiosum tissue by the inflammatory process. The preliminary results obtained in a small series of 6 patients are presented. The problems involved in the surgical treatment of urethral strictures are numerous and depend on their etiology, site and extent. 1- 3 Free skin graft urethroplasty represents a useful procedure as described previously4- 7 but we believe that the variations in the an«Lomy of the penile, bulbous and posterior urethra must be considered and the method should be performed only in selected cases. 2 Free skin patch urethroplasty is preferred for strictures in the bulbous urethra because spongioplasty is allowed for the support of the grafted area. 2•8 However, at the level of the penile urethra the corpus spongiosum cannot be used to support the grafted area because the tissue is thin and often involved in the inflammatory process, which constitutes a serious problem for the reconstruction of the mid anterior urethra. The lack of an adequate support for the patch graft between 2 tracts of undamaged urethra can lead to dilatation of the grafted area under the pressure of urinary flow and, subsequently, to the occurrence of a diverticulum. This complication does not occur when a full tract of anterior urethra is reconstructed, either by a l or 2-stage procedure, as far as the limit of the urethral meatus. In this case the pressure affects a new urethra with the same caliber and with equal :resistance to the flow over its entire length. This fact is proved clearly by the good results obtained after repair of hypospadias. We performed a new surgical technique with a skin patch graft in which adequate support was provided even in the mid anterior urethra. The patch is sutured dorsally instead of ventrally, as described commonly, and it subsequently is fixed on the tunica albuginea of the corpora. This technique was used successfully to treat strictures located in the anterior mid urethra between a distal and proximal tract of undamaged urethra. MATERIALS AND METHODS
Technique. For stenoses located in the penile urethra a double circumcising incision is made at the coronal sulcus. This incision forms a rectangular slip of prepuce skin, which must be lifted and prepared according to the standard technique. 9 Then, the penile skin is retracted as a sleeve to expose the entire pendulous urethra. The urethra then is isolated from the corpora along a considerable tract and excised longitudinally on the dorsal side as far as 2 cm. distally and proximally beyond the stricture margin (fig. 1). After the stenotic tract is exposed the length and extent of involvement of the corpus spongiosum by the inflammatory process are evaluated. At this point 3 different conditions may be noted, each of which demands a Accepted for publication Novemb-er 7, 1W3. *Requests for reprints: Department of Urology, University of Florence, viale Pieraccini, 18-50100 Florence, Italy.
particular procedure. 1) If the stenotic tract isl.5 cm. and the corpus spongiosum is not involved seriously by the inflammatory process, the stenotic mucous membrane tract is excised throughout its entire length and the 2 margins of undamaged mucous membrane are spatulated. The lacking mucous membrane tract can be replaced in 2 ways: 1) a tube spiral free patch is anastomosed distally and proximally by an overlap anastomosis to the 2 margins of the mucous membrane (fig. 4, A) or 2) a rectangular strip of skin is fixed to the corpora, the 2 free margins of the urethral mucous membrane are fixed to the spongiosum tissue, and the urethra is layed on and sutured to the patch (fig. 4, B). In this case we replace the lacking ventral mucous membrane according to the buried strip procedure of Denis Browne (fig. 4, C). In all of these procedures the spongiosum tissue is sutured to the corpora (fig. 5). For strictures located in the perineal urethra at the level of or below the penoscrotal junction a middle longitudinal incision is performed, and the urethra is isolated and removed from the corpora. The surgical treatment is completed as described previously. Urinary drainage is done via suprapubic cystostomy in all cases. Postoperative management. The urethral fenestrated catheter secured to the anterior abdominal wal1 2• 5 provides drainage of urethral secretions and reduces the dangers of infection. The urethral catheter is removed 10 days after the operation and the suprapubic cystostomy is removed after voiding cystourethrography is done. Voiding cystourethrography and urine culture are performed 3 months postoperatively and then annually for at least 5 years. Patients. From January 1980 to December 1982 this surgical
660
GRA.}'T tJRE"fI-IROPLASTY
ANTERIOR IvHDDL:E: URETHRA
B FIG. L Urethra is isolated from corpora and longitudinal dorsal incision along urethra is performed. -
FIG. 3. Schematic representation of procedure 2. A, stenotic tract is excised entirely together with mucous membrane and spongiosum tissues. B, 2 spatulated margins are sutured to form ventral gutter, and urethra is approximated and sutured to patch.
technique has been performed in 6 patients. The stenosis was located in the penile urethra in 4 patients and perinea! urethra at the penoscrotal junction in 2. The cause of the stricture was inflammatory in all patients. The strictures were located in the mid anterior urethra and the length of the stenotic tract ranged from 1 to 3.5 cm. Results were good in all cases. In 1 patient a temporary fistula healed spontaneously in 20 days. Followup was for 2 years in 3 patients, 1 year in 2 and 6 months in L The good results obtained from the procedures are shown in figure 6.
mscussmN
C
FIG. 2. Schematic representation of initial procedure. A, mucous membrane and underlying spongiosum tissues involved in inflammatory process are excised and 2 margins of mucous membrane are spatulated. B, end-to-end anastomosis of 2 spatulated margins of urethral mucous membrane to form ventral gutter. Patch graft is sutured to albuginea of underlying corpora. C, ventral mucous membrane gutter is layed on patch.
The 2-stage surgical treatment of strictures located in the anterior urethra was described well by Johanson. 10 In our a 2.. stage repair offered good results in some selected cases 3 but can cause numerous disadvantages, such as costs and much discomfort for the ··-"·--·-, note,;vrnrtti,v that the treatment of strictures located in is than that for strictures located in the posterior urethra. However, when appr,opri procedures are not used a 1-stage reconstruction can cause a high percentage of anatomic changes at the level of the repaired urethra, such as pseudodiverticula and urethrocele with chronic urinary infection, or problems for the patient, such as a post-voiding dribbling. Among the numerous 1-stage techniques used in the reconstruction of the mid anterior urethra, the procedure described by Orandi is useful but it does not allow any good support to the repaired tract because of the presence of the vascular pedicle. of the patch, 12 while other procedures using free patches 4- 7 can cause postoperative dilatation, as we have emphasized previously. 2 Others also have reported this complication with the use of unsupported free skin patches in the reconstruction of the mid urethra. 4 • 5• 7• 13• 14 Mr. Gennari provided the illustrations.
662
LENZI, BARBAGLI AND STOMACI
C FIG. 6. A, preoperative retrograde urethrography shows double stenosis in penile urethra. B, retrograde urethrography 3 months postoperatively shows good results obtained by this procedure.
REFERENCES 1. Devine, C. J., Jr. and Devine, P. C.: Urethral strictures. Editorial.
FIG. 4. Schematic representation of procedure 3. A, urethral defect is repaired with tube spiral free patch anastomosed distally and proximally by overlap anastomosis. B, after long tract of urethral mucous membrane is removed spatulated margins are fixed ventrally to spongiosum tissue. Free patch is sutured to albuginea of corpora, on which urethra is layed. C, lacking ventral mucous membrane regenerates itself on catheter according to buried strip procedure of Denis Browne.
FIG. 5. Spongiosum tissue is sutured to corpora and indwelling fenestrated catheter is placed inside urethra.
J. Urol., 123: 506, 1980. 2. Lenzi, R., Barbagli, G., Stomaci, N. and Di Cello, V.: Free full thickness skin graft urethroplasty: indications, technique and results. J. Urol., 128: 938, 1982. 3. Costantini, A., Lenzi, R., Masini, G. C., Corrado, F., Garofalo, F., Fornarola, V., Della Grazia, M. E., Rigatti, P. and Campo, B.: Trattamento chirurgico delle stenosi dell'uretra maschile. In: Relazione Ufficiale al XLVII Congresso della Societa Italiana di Urologia, Rome, October 6-9. Rome: Edigraf, 1974. 4. Devine, P. C., Horton, C. E., Devine, C. J., Sr., Devine, C. J., Jr., Crawford, H. H. and Adamson, J. E.: Use of full thickness skin grafts in repair of urethral strictures. J. Urol., 90: 67, 1963. 5. 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. 6. Devine, P. C., Fallon, B. and Devine, C. J., Jr.: Free full thickness skin graft urethroplasty. J. Urol., 116: 444, 1976. 7. Brannan, W., Ochsner, M. G., Fuselier, H. A. and Goodlet, J. S.: Free full thickness skin graft urethroplasty for urethral stricture: experience with 66 patients. J. Urol., 115: 677, 1976. 8. Turner-Warwick, R. T .: The principles of functional reconstruction of the lower urinary tract. In: Reconstructive Procedures in Surgery. Edited by P. G. Bevan. Oxford: Blackwell Scientific Publications, chapt. 11, pp. 193-233, 1982. 9. Devine, P. C., Wendelken, J. R. and Devine, C. J., Jr.: Free full thickness skin graft urethroplasty: current technique. J. Urol., 121: 282, 1979. 10. Johanson, B.: Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technique. Acta Chir. Scand., suppl. 176, 1953.
663 Lenzi; R.) Bad::.,agli Cfo, Stornaci; 1'1. and Costantini, A.: Free fuHthickness skin graft m·Pttwn,n!:a~t:v: our experience. In: The XIX International Congress of Societe Internationale d'Urologie, San Francisco, September 5-10, abstract 87, p. 38, 1982. 12. Orandi, A.: One-stage urethroplasty. Brit. J. UroL, 40: 717, 1968. 13. Brigman, J. A. and Detme, F. A.: Giant urethral diverticulum after free full thickness skin graft urethroplasty. J. Urol., 121: 523, 1979. 14. Blum, J. A., Feeney, M. J., Howe, G. E. and Steel, J. F.: Skin patch urethroplasty: 5-year fol!owup. J. Urol., 127: 909, 1982. 1
EDITORIAL COMMENTS A urethral diverticulum after a skin graft of any sort generally is associated with obstruction. This report concerns a small number of patients, some of whom have been followed for a short interval. I am concerned by the formation of a urethra by anticipating that a graft laid on the corpora will form a tube. This may have happened once but I do not believe that it would be wise to adopt this as a general procedure. Also, in the perinea! urethra, as opposed to the urethra on the shaft of the penis, defects of 1.5 cm. should be treated by mobilization and primary anastomosis rather than the insertion of any kind of a graft. C.J.D. The authors have demonstrated their ingenuity by suggesting the dorsal placement of a patch gTaft in the treatment of anterior urethral
stricture diseaseo 'I'he of the corpora has prevented secondary diverticulum i:m·m,at1
Norman B. Hodgson Department of Urology Medical College of Wisconsin Milwaukee, Wisconsin l. Quartey, J. K. M.: One-stage penile/preputial cutaneous island flap urethroplasty for urethral stricture: a preliminary report. J. Urol., 129: 284, 1983.
REPLY BY AUTHORS We agree that urethral diverticula generally are associated with obstruction but we also believe that an enlargement of the urethra after any type of unsuppmted skin graft frequently is observed even without stenosis (reference 13 in article). The last of the 4 procedures presented, that is the buried strip procedure, can be used only in exceptional cases in which serious loss of urethral tissue is present. Finally, strictures of 0.5 cm. must be treated by end-to-end anastomosis provided that the stenosis is traumatic and not inflammatory (references 2 and 3 in article).
THE JOURNAL OF UROLOGY
Copyright © 1984 by The Williams & Wilkins Co.
ONE-STAGE SKIN GRAFT URETHROPLASTY IN ANTERIOR MIDDLE URETHRA: A NEW PROCEDURE RUGGERO LENZI,* GUIDO BARBAGLI AND NICETA STOMACI From the Department of Urology, University of Florence, Florence, Italy
ABSTRACT
A new procedure with the use of a free skin patch graft for the surgical treatment of strictures located in the mid anterior urethra is described. To avoid the formation of a urethral diverticulum, the skin graft is sutured dorsally rather than ventrally and subsequently is fixed on the tunica albuginea of the corpora, which support the patch. We describe 4 different procedures according to the extent of the stenosis and the degree of involvement of the spongiosum tissue by the inflammatory process. The preliminary results obtained in a small series of 6 patients are presented. The problems involved in the surgical treatment of urethral strictures are numerous and depend on their etiology, site and extent. 1- 3 Free skin graft urethroplasty represents a useful procedure as described previously4- 7 but we believe that the variations in the an«Lomy of the penile, bulbous and posterior urethra must be considered and the method should be performed only in selected cases. 2 Free skin patch urethroplasty is preferred for strictures in the bulbous urethra because spongioplasty is allowed for the support of the grafted area. 2•8 However, at the level of the penile urethra the corpus spongiosum cannot be used to support the grafted area because the tissue is thin and often involved in the inflammatory process, which constitutes a serious problem for the reconstruction of the mid anterior urethra. The lack of an adequate support for the patch graft between 2 tracts of undamaged urethra can lead to dilatation of the grafted area under the pressure of urinary flow and, subsequently, to the occurrence of a diverticulum. This complication does not occur when a full tract of anterior urethra is reconstructed, either by a l or 2-stage procedure, as far as the limit of the urethral meatus. In this case the pressure affects a new urethra with the same caliber and with equal :resistance to the flow over its entire length. This fact is proved clearly by the good results obtained after repair of hypospadias. We performed a new surgical technique with a skin patch graft in which adequate support was provided even in the mid anterior urethra. The patch is sutured dorsally instead of ventrally, as described commonly, and it subsequently is fixed on the tunica albuginea of the corpora. This technique was used successfully to treat strictures located in the anterior mid urethra between a distal and proximal tract of undamaged urethra. MATERIALS AND METHODS
Technique. For stenoses located in the penile urethra a double circumcising incision is made at the coronal sulcus. This incision forms a rectangular slip of prepuce skin, which must be lifted and prepared according to the standard technique. 9 Then, the penile skin is retracted as a sleeve to expose the entire pendulous urethra. The urethra then is isolated from the corpora along a considerable tract and excised longitudinally on the dorsal side as far as 2 cm. distally and proximally beyond the stricture margin (fig. 1). After the stenotic tract is exposed the length and extent of involvement of the corpus spongiosum by the inflammatory process are evaluated. At this point 3 different conditions may be noted, each of which demands a Accepted for publication Novemb-er 7, 1W3. *Requests for reprints: Department of Urology, University of Florence, viale Pieraccini, 18-50100 Florence, Italy.
particular procedure. 1) If the stenotic tract is
660
GRA.}'T tJRE"fI-IROPLASTY
ANTERIOR IvHDDL:E: URETHRA
B FIG. L Urethra is isolated from corpora and longitudinal dorsal incision along urethra is performed. -
FIG. 3. Schematic representation of procedure 2. A, stenotic tract is excised entirely together with mucous membrane and spongiosum tissues. B, 2 spatulated margins are sutured to form ventral gutter, and urethra is approximated and sutured to patch.
technique has been performed in 6 patients. The stenosis was located in the penile urethra in 4 patients and perinea! urethra at the penoscrotal junction in 2. The cause of the stricture was inflammatory in all patients. The strictures were located in the mid anterior urethra and the length of the stenotic tract ranged from 1 to 3.5 cm. Results were good in all cases. In 1 patient a temporary fistula healed spontaneously in 20 days. Followup was for 2 years in 3 patients, 1 year in 2 and 6 months in L The good results obtained from the procedures are shown in figure 6.
mscussmN
C
FIG. 2. Schematic representation of initial procedure. A, mucous membrane and underlying spongiosum tissues involved in inflammatory process are excised and 2 margins of mucous membrane are spatulated. B, end-to-end anastomosis of 2 spatulated margins of urethral mucous membrane to form ventral gutter. Patch graft is sutured to albuginea of underlying corpora. C, ventral mucous membrane gutter is layed on patch.
The 2-stage surgical treatment of strictures located in the anterior urethra was described well by Johanson. 10 In our a 2.. stage repair offered good results in some selected cases 3 but can cause numerous disadvantages, such as costs and much discomfort for the ··-"·--·-, note,;vrnrtti,v that the treatment of strictures located in is than that for strictures located in the posterior urethra. However, when appr,opri procedures are not used a 1-stage reconstruction can cause a high percentage of anatomic changes at the level of the repaired urethra, such as pseudodiverticula and urethrocele with chronic urinary infection, or problems for the patient, such as a post-voiding dribbling. Among the numerous 1-stage techniques used in the reconstruction of the mid anterior urethra, the procedure described by Orandi is useful but it does not allow any good support to the repaired tract because of the presence of the vascular pedicle. of the patch, 12 while other procedures using free patches 4- 7 can cause postoperative dilatation, as we have emphasized previously. 2 Others also have reported this complication with the use of unsupported free skin patches in the reconstruction of the mid urethra. 4 • 5• 7• 13• 14 Mr. Gennari provided the illustrations.
662
LENZI, BARBAGLI AND STOMACI
C FIG. 6. A, preoperative retrograde urethrography shows double stenosis in penile urethra. B, retrograde urethrography 3 months postoperatively shows good results obtained by this procedure.
REFERENCES 1. Devine, C. J., Jr. and Devine, P. C.: Urethral strictures. Editorial.
FIG. 4. Schematic representation of procedure 3. A, urethral defect is repaired with tube spiral free patch anastomosed distally and proximally by overlap anastomosis. B, after long tract of urethral mucous membrane is removed spatulated margins are fixed ventrally to spongiosum tissue. Free patch is sutured to albuginea of corpora, on which urethra is layed. C, lacking ventral mucous membrane regenerates itself on catheter according to buried strip procedure of Denis Browne.
FIG. 5. Spongiosum tissue is sutured to corpora and indwelling fenestrated catheter is placed inside urethra.
J. Urol., 123: 506, 1980. 2. Lenzi, R., Barbagli, G., Stomaci, N. and Di Cello, V.: Free full thickness skin graft urethroplasty: indications, technique and results. J. Urol., 128: 938, 1982. 3. Costantini, A., Lenzi, R., Masini, G. C., Corrado, F., Garofalo, F., Fornarola, V., Della Grazia, M. E., Rigatti, P. and Campo, B.: Trattamento chirurgico delle stenosi dell'uretra maschile. In: Relazione Ufficiale al XLVII Congresso della Societa Italiana di Urologia, Rome, October 6-9. Rome: Edigraf, 1974. 4. Devine, P. C., Horton, C. E., Devine, C. J., Sr., Devine, C. J., Jr., Crawford, H. H. and Adamson, J. E.: Use of full thickness skin grafts in repair of urethral strictures. J. Urol., 90: 67, 1963. 5. 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. 6. Devine, P. C., Fallon, B. and Devine, C. J., Jr.: Free full thickness skin graft urethroplasty. J. Urol., 116: 444, 1976. 7. Brannan, W., Ochsner, M. G., Fuselier, H. A. and Goodlet, J. S.: Free full thickness skin graft urethroplasty for urethral stricture: experience with 66 patients. J. Urol., 115: 677, 1976. 8. Turner-Warwick, R. T .: The principles of functional reconstruction of the lower urinary tract. In: Reconstructive Procedures in Surgery. Edited by P. G. Bevan. Oxford: Blackwell Scientific Publications, chapt. 11, pp. 193-233, 1982. 9. Devine, P. C., Wendelken, J. R. and Devine, C. J., Jr.: Free full thickness skin graft urethroplasty: current technique. J. Urol., 121: 282, 1979. 10. Johanson, B.: Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technique. Acta Chir. Scand., suppl. 176, 1953.
663 Lenzi; R.) Bad::.,agli Cfo, Stornaci; 1'1. and Costantini, A.: Free fuHthickness skin graft m·Pttwn,n!:a~t:v: our experience. In: The XIX International Congress of Societe Internationale d'Urologie, San Francisco, September 5-10, abstract 87, p. 38, 1982. 12. Orandi, A.: One-stage urethroplasty. Brit. J. UroL, 40: 717, 1968. 13. Brigman, J. A. and Detme, F. A.: Giant urethral diverticulum after free full thickness skin graft urethroplasty. J. Urol., 121: 523, 1979. 14. Blum, J. A., Feeney, M. J., Howe, G. E. and Steel, J. F.: Skin patch urethroplasty: 5-year fol!owup. J. Urol., 127: 909, 1982. 1
EDITORIAL COMMENTS A urethral diverticulum after a skin graft of any sort generally is associated with obstruction. This report concerns a small number of patients, some of whom have been followed for a short interval. I am concerned by the formation of a urethra by anticipating that a graft laid on the corpora will form a tube. This may have happened once but I do not believe that it would be wise to adopt this as a general procedure. Also, in the perinea! urethra, as opposed to the urethra on the shaft of the penis, defects of 1.5 cm. should be treated by mobilization and primary anastomosis rather than the insertion of any kind of a graft. C.J.D. The authors have demonstrated their ingenuity by suggesting the dorsal placement of a patch gTaft in the treatment of anterior urethral
stricture diseaseo 'I'he of the corpora has prevented secondary diverticulum i:m·m,at1
Norman B. Hodgson Department of Urology Medical College of Wisconsin Milwaukee, Wisconsin l. Quartey, J. K. M.: One-stage penile/preputial cutaneous island flap urethroplasty for urethral stricture: a preliminary report. J. Urol., 129: 284, 1983.
REPLY BY AUTHORS We agree that urethral diverticula generally are associated with obstruction but we also believe that an enlargement of the urethra after any type of unsuppmted skin graft frequently is observed even without stenosis (reference 13 in article). The last of the 4 procedures presented, that is the buried strip procedure, can be used only in exceptional cases in which serious loss of urethral tissue is present. Finally, strictures of 0.5 cm. must be treated by end-to-end anastomosis provided that the stenosis is traumatic and not inflammatory (references 2 and 3 in article).