Anterior Urethral Strictures: Experience with Free Graft Urethroplasty

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ANTERIOR URETHRAL STRICTURES: EXPERIENCE WITH FREE GRAFT URETHROPLASTY WILLIAM ERANI\A1\J, MIMS G. OCHSNER

AND

HAROLD A. FUSELIER, elR.

From the Department of Urolo 1;:v, Ochsner Clinic and Ochsner Foundation Hospital, New Orleans. Louisiana

for repeated urethral dilatations at 3-month intervals or less.

Urethral stricture is a common and potentially serious urological problem. Many methods of managing anterior urethral stricture have been advocated-the easiest and most conservative approach being urethral dilatation. However, repeated dilatations are necessary in many patients since few are cured. Internal urethrotomy, external urethrotomy and excision of the stricture with re-anastomosis have been used to circumvent the need for these periodic dilatations. 1 In 1953 Johanson 2 advocated a 2-stage urethroplastic procedure which was later modified by Leadbetter. 3 In 1959 Turner-Warwick 4 introduced the 2-stage scrotal inlay procedure and in 1963 Devine and associates'· 6 introduced a 1-stage procedure using a full thickness skin graft. This procedure produced an excellent cure rate with low morbidity and mortality. Since 1969 we have used a 1-stage full thickness skin graft procedure as the surgical treatment of urethral stricture at Ochsner Clinic and affiliated institutions.* This report deals with our preoperative evaluation, surgical technique and results in 16 cases.t The indications for an operation included: l) strictures in young men that would require periodic even though infrequent dilatations, 2) sepsis, either periurethral abscess or serious urinary tract infection, 3) impassable stricture and 4) necessity

PREOPERATIVE EVALUATION

Retrograde urethrogram, excretory urogram and cystourethrogram were obtained in all cases of suspected urethral strictures. Panendoscopy with urethral calibration was done when anatomically possible. Measurement of the residual urine and urine culture were done on selected patient.s. In our series of 16 cases, the strictures were located either in the bulbar urethra or in the pendulous urethra at the penoscrotal junction (table 1). The patients ranged in age from 13 to 71 years with an average of 50 years. The causes of the strictures are given in table 2. TECHNIQUE

After general or lumbar anesthesia the patient is placed in the lithotomy position and the genitalia and perineum are cleansed with antiseptic. Methylene blue is then injected into the urethra to clearly demarcate the urethral stricture and urethral mucosa. A urethral sound is inserted to the site of the stricture and a vertical skin incision is made in the perineum. The perineum is opened in layers sharply cutting through Colles' fascia. The bulbocavernosus muscle is separated TABLE

Accepted for publication July 21. 1972. Read at annual meeting of Southeastern Section. American Urological Association, New Orleans, Louisiana, March 26-:iO, 1972. 1 Hand, J. R.: Surgery of the penis and urethra. In Urology, 3rd ed. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: v,;_ B. Saunders Co., vol. :3. pp. 2594-2598, 1970. 'Johanson, B.: Reconstruction of the male urethra in

strictures. Application of the buried intact epithelium technique. Acta Chir. Scand .. suppl. 176. 1953. 3 Leadbetter, G. ,Jr.: A simplified for strictures of the urethra. ,J. Urol.,

1. Location of urethral strictures in 16 patients

Bulbar urethra: Proximal bulb. 10 Mid or distal bulb. 4 Pendulous urethra at penoscrotal junction

14

Total ~~~~-----~------

16

TABLE

'.2.

:2. Causes of urethral strictures in 16 patients '\Jo. Pts.

1960.

A technique for posterior

Congenital Traumatic: Fracture of Straddle Gunshot wound to buttock and urethra. Iatrogenic: Transurethral resection of prostate. 6 Urethral dilatation. 1 Cystoscopy". 1 Post-infective Gonococcal urethritis. :l

1960.

E.. Devine. C. ,J., Sr.. H. H. and Adamson. J. E.: Use of full thickness skin grafts in repair of urethral strictures. ,J. Urol.. 90: 67, 1963. 6 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. * Mobile General Hospital, Mobile, Alabama; E. A. Conway Charity Hospital, Monroe, Louisiana. t Four cases were from the Tulane Urological Service, Charity Hospital of Louisiana, New Orleans, Louisiana.

Total

265

16

266

BRANNAN, OCHSNER AND FUSELIER

FIG. 1. A, incision. B, urethral stricture exposed and incised. C, free graft sutured into stricture. D, completion of free graft urethroplasty.

in the midline. The urethra is opened over the sound or filiform and the incision is extended 1 cm. distal to and proximal to the limits of the stricture. A 24 French silicone-coated Foley catheter is inserted into the bladder. A full-thickness patch graft is then obtained from the dorsal shaft of the penis, prepuce or other non-hairbearing skin. The graft is defatted and trimmed to size. The patch of skin is sutured to the urethra using interrupted 4-zero polyglycolic acid (dexon)* suture with the epithelial surface facing the urethral lumen (fig. 1). The corpus spongiosum, bulbocavernosus muscle, Colles' fascia and skin are closed in layers. No drain is used. Urethral catheter drainage is maintained for 14 days. RESULTS

Since March 1969, 16 urethral strictures have been repaired with this procedure (table 3). The dorsum of the penis or prepuce was used as the donor site in 15 patients and the brachial area in 1. In 6 patients the operation was done 12 to 36 months ago and one of these has been lost to followup. Of the remaining 5 patients, 4 have excellent results and a recurrent stricture was noted in

* Davis and Geck, Pearl River, New York 10965.

1. This patient has been easily dilated periodically with a 24 French Van Buren sound. The intervals between dilatations have been increasing, the last being 5 months. Followup has ranged from 6 to 12 months in 7 patients and 3 to 6 months in 3 patients. In the former group a recurrent stricture was treated with urethral dilatation in 1 case. Excellent voiding streams are present in the others. Retrograde urethrogram or a voiding cystourethrogram or both have been performed 2 to 6 months postoperatively and selected results are shown in figures 2 and 3. SUMMARY

Our experience with a 1-stage procedure, using free patch grafts for correction of urethral strictures, has been reported. In the 15 cases that are TABLE

3. Results of urethroplasty in 16 patients Results

Mos. Followup

12-36 6-12 3-6

Excellent (86%) 4 6 3

Require Dilatation

Lost to Followup

267

ANTERIOR URETHRAL STRICTURES

FIG. 2. A, preoperative retrograde urethrogram in 25year-old patient with congenital stricture. B, urethrogram 10 months postoperatively. Patient is still asymptomatic after 12 months.

available for followup, an excellent voiding pattern is present in 13 and urethral dilatation is no longer necessary. We advocate this 1-stage procedure for repair of selected anterior urethral stricture.

FIG. 3. A, preoperative retrograde urethrogram of 64year-old patient who had transurethral resection of prostate 9 years previously. B, voiding urethrogram 3 months postoperatively. Patient still asymptomatic after 5 months. ADDENDUM

The procedure has now been used in 23 patients with adequate followup. None of the additional 7 patients has required dilatation.