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Dorsal Free Graft Urethroplasty
0022-5317/96/155 1-0123$03.00/0 Tw .IIKKNAL OF UKOLOGY C o p right 0 1996 by AMERICAN UKOLWICAL &SOCIATION, LNc.
Vol. 155, 123-126. January 1996 Printed in U S A .
DORSAL FREE GRAFT URETHROPLASTY GUIDO BARBAGLI, CESARE SELLI, ALDO TOSTO AND ENZO PALMINTERI From the Department of Urology, Universit-y of Florence, Florence, Italy
ABSTRACT
Purpose: Dorsal free graft urethroplasty w a s performed t o reduce t h e incidence of urethrocele. Materials and Methods: We treated 12 patients with penile and 13 with bulbous strictures. Of the 13 p a t i e n t s with a bulbous stricture 6 received a dorsally placed tube graft and 7 received a p a t c h graft. Results: Temporary fistulas were seen on postoperative urethrography in 5 cases but they all resolved spontaneously. At a mean followup of 35.8 months clinical and radiological findings were excellent in 23 cases and good i n 2. No signs of graft weakening, such as post-void dribbling o r diminished ejaculation, were apparent. Conclusions: The use of free skin grafts for urethral reconstruction is anatomically healthier in the dorsal than in the ventral position.
KEYWORDS:urethra. urethral stricture A wide array of techniques are used in reconstructive surgery for urethral stricture disease' and modifications are
continuously added.2-4 Pedicled or free skin grafts are used most frequently for the majority of strictures.s7 The techniques currently adopted advance graft apposition on the ventral surface of the urethra, which can result in weakening of the corpus spongiosum and development of pseudo-diverticulum or a urethrocele, causing post-void dribbling and ejaculatory failure.6 Based on the principles of the buried skin strip suggested by Browne,8 the dorsal urethral widening described by Monseur" and the use of free skin grafts proposed by Devine et a l , l O we developed the technique of dorsal free graft urethroplasty. This procedure involves a free skin graft on the corpora cavernosa, urethral rotation and longitudinal opening along its dorsal surface, and suture to a patch or tubed graft. The technique is applicable to strictures of the penile and bulbous urethra with minimal modifications. When the free preputial skin graft is applied dorsally instead of ventrally it is mechanically supported by the corpora cavernosa and receives its vascular supply from the surrounding corpus hpongiosum, which avoids graft weakening. PATIENTS AND METHODS
From 1990 to 1993, 25 men 16 to 86 years old underwent dorsal free graft urethroplasty. The strictures were situated 111 the penile urethra in 12 cases and in the bulbous urethra i n 13. Stricture etiology was iatrogenic in 15 patients, traumatic in 4, inflammatory in 4 and unknown in 2. The length of the strictures of the penile urethra ranged between 1.5 and 5 cm., and strictures of the bulbous urethra were 2.5 to 6 cm. long. All patients were evaluated preoperatively with retrograde and voiding urethrography to define stricture location, and ultrasonography was performed to evaluate the extent of spongiofibrosis.11 All patients were uncircumcised, and the foreskin provided a graft of sufficient size and length. The technique used for strictures of the penile urethra involves a double circumferential subcoronal incision for graft harvesting and penile denudation. The urethra is completely mobilized from the corpora cavernosa and rotated 180 degrees. and the stenotic tract is opened along its dorsal surface (fig. 1, A). The patch graft is-sutured to the corpora cavernosa, and stay sutures are placed on the edges of the dorsal incision of the urethra and on the extremities of the Accepted for publication May 19, 1995.
sutured free patch (fig. 1, B ) . The opened urethra is derotated and its margins are sutured to the margins of the underlying graft (fig. 1, C ) . At completion of the procedure the grafted area is entirely covered by the urethra (fig. 1, D). The penile skin is reapproximated and a 12F silicone Foley catheter is left indwelling for 14 days. Suprapubic cystostomy is not necessary. Two different techniques were used for strictures of the bulbous urethra. For tubularized dorsal free patch graft urethroplasty, the urethra is extensively mobilized, rotated 180 degrees and incised along its dorsal surface with complete excision of the stenotic tract, leaving intact the ventral aspect of the corpus spongiosum. The proximal and distal mucosal edges are spatulated, and the free skin graft is sutured to the proximal mucosal edge and tubularized over a 16F silicone Foley catheter. The distal anastomosis is completed and, if possible, the corpus spongiosum is closed without tension over the graft. The urethra is rotated back to its original position and the grafted area is completely covered by the bulbous urethra. Suprapubic cystostomy is mandatory. The other technique of dorsal patch graft urethroplasty for strictures of the bulbous urethra involves a complete section of the urethra at the level of the stricture, and proximal and distal urethral mobilization. The proximal mucosal edge is spatulated and splayed over the corpora cavernosa, the free patch graft is sutured to the corpora cavernosa above it and its lower margin is sutured to the mucosal edge of the urethra (fig. 2, A). The mobilized distal urethra is widely opened along its dorsal surface (fig. 2, A). The left mucosal margin of the opened distal urethra is sutured to the left side of the patch graft (fig. 2, B ) . The urethra is rotated back to its original position and the right urethral margin is sutured to the right side of the patch graft (fig. 2, C ) .At completion the grafted area is entirely covered by the urethra (fig. 2, D ) . A 16F Foley catheter and a suprapubic cystostomy are placed. Two weeks after penile urethroplasty the bladder is filled with contrast medium, the Foley catheter is removed and voiding urethrography is done. Two weeks after bulbous urethroplasty the Foley catheter is removed and voiding urethrography is obtained by injecting contrast medium from the suprapubic cystostomy. Voiding cystourethrography is done a t the time of hospital discharge and yearly thereafter. During the first year uroflowmetry is performed every 4 months and radiological studies are repeated only when urine flow is less than 14 ml. per second. 123
124
DORSAL FREE GRAFT URETHROPLASTY
A
C
n
D
FIG. 1. Technique of dorsal free patch graft urethroplasty for strictures of penile urethra. A, mobilization, rotation of 180 degrees and dorsal incision of urethra. B , apposition of graft on corpora cavernosa and placement of stay sutures on urethral margns. C, urethral de-rotation over patch. D, patch graft is completely covered by urethra.
FIG. 2. Technique of dorsal free patch graR urethroplasty for strictures of bulbous urethra. A, dorsal opening of transected distal urethra and apposition of graft on corpora cavernosa. B, left urethral margin is sutured to l e e side of patch. C, suture of right margin and urethral de-rotation over patch. D, patch graft is completely covered by urethra.
RESULTS Of the 12 patients who underwent repair of strictures of Our clinical series was closed in December 1993 to allow the penile urethra an anastomotic fistula was evident at for a followup on the reconstructed urethras exceeding 1 postoperative voiding usethrography in 3, which resolved year, since we believe that this is the minimum time neces- after 1 week of repeated catheterization. With a mean fols a r y to evaluate the results of urethral reconstruction. All lowup of 33 months (range 18 to 56) all patients had a uroflow patients underwent final clinical and radiological evaluation level of greater than 14 ml. per second. Of the 6 patients who in December 1994. underwent tubularized free patch graft urethroplasty a tem-
DORSAL FREE GRAFT URETHROPLASTY
125
1211;. 3. A, preoperative retrograde urethrography shows double stricture of bulbous urethra for combined length of 6 cm. B , voiding unthrography 14 days after surgery reveals no ventral weakening in grafted area.
H i ~ s d t sof urethroplasty with pedicled and free full thickness skin grafts sutured on the ventral surface of the urethra References Webster and Robertsons M u n d y and Stephenson" Brannan et al"
GraRType Pedicled Pedicled
Free full
NO. % compli~a- % &penCases tionhte tionhte 11 3 2 48 25 8 66 17 6
thickness Dcvine et alZo
__
Free full
60
12
thickness
porary postoperative fistula was documented in 2 but it resolved after 1 week of further catheterization. These patients presented with a bifid or splayed urinary stream, although uroflow was greater than 14 ml. Per second at a mean followup of 41.6 months (range 23 to 55). Of the 7 patients who underwent dorsal patch graft UrethroPlastY voiding w e thrography at 2 weeks showed no fistulas, and the uroflow has remained satisfactory in all at a mean fOllOWUP of 35.5 months (range 20 to 54). Post-void dribbling or diminished ejaculation did not occur i n any patient, and radiographic studies failed to show recurrent strictures or weakening of the grafted areas after a mean interval of 35.8 months. In the entire Series further dilatation or intervention was not necessary. DISCUSSION
The primary indication for use of dorsal free patch urethroplasty for strictures of the penile urethra is a lesion longer than 1 cm. when end-to-end anastomosis can cause chordee." Contraindications are extensive spongiofibrosis causing almost complete obliteration of the urethral lumen, since opening of the urethra would result in an inadequate surface to be sutured to the dorsal Patch graft, and presence Of chronic infection, either Of the Upper Urinary tract O r locally 'associated bladder and urethral Stones, urethral Pseudodiverticula or fistulas and paraurethral abscesses). The length of the stricture is not a contraindication for this Procedure. The indication for strictures of the bulbous urethra is a lesion longer than 2 cm. when removal of the mucosal lining and surrounding spongiolysis is required. Tubularized free grafts were initially used for losses of urethral continuity greater than 3 cm. but recently dorsal free patch graft urethroplasty also has been used for long strictures with good results (fig. 3). The former procedure is technically more complex, and more often presents postoperative Problems and less satisfactory functional outcome as documented in our earlier experience. From a technical point of view dorsal free graft urethro-
plasty is easier to perform than pedicled graft urethroplasty.13-15 We believe that a dorsally placed patch or tube free graft results in a lower incidence of necrosis as opposed to a ventral patch, since it receives better mechanical support and adequate vascular supply. We also believe that a dorsal graft produces better results than a pedicled ventral graft, since there is less extensive degloving of the penis, no ventral weakening due to formation of urethrocele and, even if a patch graft should necrose, the urethral mucosa regenerates according to the principles of Brownes and Monseurg provided that a catheter is left indwelling for sufficient time. In regard to strictures of the bulbous urethra, the dorsal approach to the diseased segment requires a less extensive openingof the spongy tissue, since the urethral lumen is dorsally located. With this approach bleeding from the corpus spongiosum is considerably reduced and mechanical weakening is virtually impossible. menpedicled grafts are applied to the bulbous urethra with a ventral approach, the extensively incised corpus spongiosum cannot be reapproximated Over them and, in fact, a relatively high incidence of pseudo-diverticula, whose size is sometimes considerable,16. 17 has been documented,6 The results of 2 series of pedicled graft urethroplasty and 2 series of free full thickness graft urethroplasty are shown in the table. The complication rate r a g e d from 3 to 25% and the reoperation rate ranged from 2 to 8%.1S-z0 Although our series is too small and followup is relatively short, to date there have been no significant complications and reintervention has not been required. CONCLUSIONS
me radiological
and findings of 25 who underwent dorsal free graft urethroplasty with a mean followup of 35.8 months indicate that this procedure not only maintains urethral patency but also avoids graft weakening, which has been documented in ventral free or pedicled graft urethroplasty. Therefore, we believe that the use of free skin grafts for strictures of the penile or bulbous urethra is ariatomically healthier in the dorsal than in the ventral position. REFERENCES
1. Webster, G.D.and mow,J. M.: Urethral stricture disease. In: Clinical Urology. Edited by R. J. Krane, M. B. Siroky and J. M. Fitzpatrick. Philadelphia: J. B. Lippincott Co., pp. 906-924, 1994. 2. Keating, M. A., Cartwright, P. C. and Duckett, J. W.: Bladder mucosa in urethral reconstructions. J. Urol., 144: 827, 1990. 3. Burger, R.A,, Muller, S. C., El-Damanhoury,H., Tschakaloff,A., Riedmiller, H. and Hohenfellner, R.: The buccal mucosal gr& for urethral reconstruction:a preliminary report. J. Urol., 1 4 2 662, 1992.
126
DORSAL FREE GRAFT URETHROPLASTY
4. McAniich, J. W.: Reconstruction of extensive urethral strictures: circular fasciocutaneous penile flap. J. Urol., 149: 488, 1993. 5. Webster, G.D., Brown, M.W., Koefoot, R. B., Jr. and Sihelnick, S.: Suboptimal results in full thickness graft urethroplasty using an extrapenile skin donor site. J. Urol., 131: 1082,1984. 6. Webster, G. D. and Robertson, C. N.:The vascularized skin island urethroplasty: its role and results in urethral stricture management. J. Urol., 133:31, 1985. 7. Turner-Warwick, R.: Principles of urethral reconstruction. In: Reconstructive Urology. Edited by G. D. Webster, R. Kirby, L. King and B. Goldwasser. Boston: Blackwell Scientific F'ublications, vol. 2,pp. 609-642, 1993. 8. Browne, D.: Operation for hypospadias. Proc. Roy. Soc. Med., 42: 466, 1949. 9. Monseur, J.: L'elargissement de l ' d t r e au moyen du plan sus uretral. Bilan a p d s 13 an6 sur 219 cas.J. d'urol., 6:439,1980. 10. Devine, P. C.,Wendelken, J. R. and Devine, C. J., Jr.: Free full thickness skin graft urethroplasty: current technique. J. Urol., 121: 282, 1979. 11. Barbagli, G., Menchi, I., Amorosi, A., Selli, C. and Azzaro, F.: Bacteriologic, histologic and ultrasonographic findings in
strictures recurring after urethrotomy: a preliminary study.
Scand. J. Urol. Nephrol., 29: 193, 1995. 12. Webster, G.D.:Personal communication. 13. Orandi, A: One-stage urethroplasty. Brit. J. Urol., 40: 717,1968. 14. Duckett, J. W., Jr.: Transverse preputial island flap technique for repair of severe hypospadias. Urol. Clin. N. Amer., 7: 423, 1980. 15. Quartey, J. K. M.: One-stage peddpreputial island flap ur+ throplasty for urethral stricture. J. Urol., 134.474, 1985. 16. Brigman, G. A. and Deture, F. A.: Giant urethral diverticulum &r free full thickness skin graft urethroplasty. J. Urol., 121: 523,1979. 17. Blum, J. A,Feeney, M. J., Howe, G. E. and Steel, J. F.: Skin patch urethroplasty: 5-year followup. J. Urol., 127: 909,1982. 18. Mundy, A. R. and Stephenson, T. P.: Pedicled preputial patch urethroplasty. Brit. J. Urol., 61: 48, 1988. 19. 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., 116 677,1976. 20. Devine, P. C., Fallon, B. and Devine, C. J., Jr.: Free full thick. ness skin graft urethroplasty. J. Urol., 116 444, 1976.
Vol. 155, 123-126. January 1996 Printed in U S A .
DORSAL FREE GRAFT URETHROPLASTY GUIDO BARBAGLI, CESARE SELLI, ALDO TOSTO AND ENZO PALMINTERI From the Department of Urology, Universit-y of Florence, Florence, Italy
ABSTRACT
Purpose: Dorsal free graft urethroplasty w a s performed t o reduce t h e incidence of urethrocele. Materials and Methods: We treated 12 patients with penile and 13 with bulbous strictures. Of the 13 p a t i e n t s with a bulbous stricture 6 received a dorsally placed tube graft and 7 received a p a t c h graft. Results: Temporary fistulas were seen on postoperative urethrography in 5 cases but they all resolved spontaneously. At a mean followup of 35.8 months clinical and radiological findings were excellent in 23 cases and good i n 2. No signs of graft weakening, such as post-void dribbling o r diminished ejaculation, were apparent. Conclusions: The use of free skin grafts for urethral reconstruction is anatomically healthier in the dorsal than in the ventral position.
KEYWORDS:urethra. urethral stricture A wide array of techniques are used in reconstructive surgery for urethral stricture disease' and modifications are
continuously added.2-4 Pedicled or free skin grafts are used most frequently for the majority of strictures.s7 The techniques currently adopted advance graft apposition on the ventral surface of the urethra, which can result in weakening of the corpus spongiosum and development of pseudo-diverticulum or a urethrocele, causing post-void dribbling and ejaculatory failure.6 Based on the principles of the buried skin strip suggested by Browne,8 the dorsal urethral widening described by Monseur" and the use of free skin grafts proposed by Devine et a l , l O we developed the technique of dorsal free graft urethroplasty. This procedure involves a free skin graft on the corpora cavernosa, urethral rotation and longitudinal opening along its dorsal surface, and suture to a patch or tubed graft. The technique is applicable to strictures of the penile and bulbous urethra with minimal modifications. When the free preputial skin graft is applied dorsally instead of ventrally it is mechanically supported by the corpora cavernosa and receives its vascular supply from the surrounding corpus hpongiosum, which avoids graft weakening. PATIENTS AND METHODS
From 1990 to 1993, 25 men 16 to 86 years old underwent dorsal free graft urethroplasty. The strictures were situated 111 the penile urethra in 12 cases and in the bulbous urethra i n 13. Stricture etiology was iatrogenic in 15 patients, traumatic in 4, inflammatory in 4 and unknown in 2. The length of the strictures of the penile urethra ranged between 1.5 and 5 cm., and strictures of the bulbous urethra were 2.5 to 6 cm. long. All patients were evaluated preoperatively with retrograde and voiding urethrography to define stricture location, and ultrasonography was performed to evaluate the extent of spongiofibrosis.11 All patients were uncircumcised, and the foreskin provided a graft of sufficient size and length. The technique used for strictures of the penile urethra involves a double circumferential subcoronal incision for graft harvesting and penile denudation. The urethra is completely mobilized from the corpora cavernosa and rotated 180 degrees. and the stenotic tract is opened along its dorsal surface (fig. 1, A). The patch graft is-sutured to the corpora cavernosa, and stay sutures are placed on the edges of the dorsal incision of the urethra and on the extremities of the Accepted for publication May 19, 1995.
sutured free patch (fig. 1, B ) . The opened urethra is derotated and its margins are sutured to the margins of the underlying graft (fig. 1, C ) . At completion of the procedure the grafted area is entirely covered by the urethra (fig. 1, D). The penile skin is reapproximated and a 12F silicone Foley catheter is left indwelling for 14 days. Suprapubic cystostomy is not necessary. Two different techniques were used for strictures of the bulbous urethra. For tubularized dorsal free patch graft urethroplasty, the urethra is extensively mobilized, rotated 180 degrees and incised along its dorsal surface with complete excision of the stenotic tract, leaving intact the ventral aspect of the corpus spongiosum. The proximal and distal mucosal edges are spatulated, and the free skin graft is sutured to the proximal mucosal edge and tubularized over a 16F silicone Foley catheter. The distal anastomosis is completed and, if possible, the corpus spongiosum is closed without tension over the graft. The urethra is rotated back to its original position and the grafted area is completely covered by the bulbous urethra. Suprapubic cystostomy is mandatory. The other technique of dorsal patch graft urethroplasty for strictures of the bulbous urethra involves a complete section of the urethra at the level of the stricture, and proximal and distal urethral mobilization. The proximal mucosal edge is spatulated and splayed over the corpora cavernosa, the free patch graft is sutured to the corpora cavernosa above it and its lower margin is sutured to the mucosal edge of the urethra (fig. 2, A). The mobilized distal urethra is widely opened along its dorsal surface (fig. 2, A). The left mucosal margin of the opened distal urethra is sutured to the left side of the patch graft (fig. 2, B ) . The urethra is rotated back to its original position and the right urethral margin is sutured to the right side of the patch graft (fig. 2, C ) .At completion the grafted area is entirely covered by the urethra (fig. 2, D ) . A 16F Foley catheter and a suprapubic cystostomy are placed. Two weeks after penile urethroplasty the bladder is filled with contrast medium, the Foley catheter is removed and voiding urethrography is done. Two weeks after bulbous urethroplasty the Foley catheter is removed and voiding urethrography is obtained by injecting contrast medium from the suprapubic cystostomy. Voiding cystourethrography is done a t the time of hospital discharge and yearly thereafter. During the first year uroflowmetry is performed every 4 months and radiological studies are repeated only when urine flow is less than 14 ml. per second. 123
124
DORSAL FREE GRAFT URETHROPLASTY
A
C
n
D
FIG. 1. Technique of dorsal free patch graft urethroplasty for strictures of penile urethra. A, mobilization, rotation of 180 degrees and dorsal incision of urethra. B , apposition of graft on corpora cavernosa and placement of stay sutures on urethral margns. C, urethral de-rotation over patch. D, patch graft is completely covered by urethra.
FIG. 2. Technique of dorsal free patch graR urethroplasty for strictures of bulbous urethra. A, dorsal opening of transected distal urethra and apposition of graft on corpora cavernosa. B, left urethral margin is sutured to l e e side of patch. C, suture of right margin and urethral de-rotation over patch. D, patch graft is completely covered by urethra.
RESULTS Of the 12 patients who underwent repair of strictures of Our clinical series was closed in December 1993 to allow the penile urethra an anastomotic fistula was evident at for a followup on the reconstructed urethras exceeding 1 postoperative voiding usethrography in 3, which resolved year, since we believe that this is the minimum time neces- after 1 week of repeated catheterization. With a mean fols a r y to evaluate the results of urethral reconstruction. All lowup of 33 months (range 18 to 56) all patients had a uroflow patients underwent final clinical and radiological evaluation level of greater than 14 ml. per second. Of the 6 patients who in December 1994. underwent tubularized free patch graft urethroplasty a tem-
DORSAL FREE GRAFT URETHROPLASTY
125
1211;. 3. A, preoperative retrograde urethrography shows double stricture of bulbous urethra for combined length of 6 cm. B , voiding unthrography 14 days after surgery reveals no ventral weakening in grafted area.
H i ~ s d t sof urethroplasty with pedicled and free full thickness skin grafts sutured on the ventral surface of the urethra References Webster and Robertsons M u n d y and Stephenson" Brannan et al"
GraRType Pedicled Pedicled
Free full
NO. % compli~a- % &penCases tionhte tionhte 11 3 2 48 25 8 66 17 6
thickness Dcvine et alZo
__
Free full
60
12
thickness
porary postoperative fistula was documented in 2 but it resolved after 1 week of further catheterization. These patients presented with a bifid or splayed urinary stream, although uroflow was greater than 14 ml. Per second at a mean followup of 41.6 months (range 23 to 55). Of the 7 patients who underwent dorsal patch graft UrethroPlastY voiding w e thrography at 2 weeks showed no fistulas, and the uroflow has remained satisfactory in all at a mean fOllOWUP of 35.5 months (range 20 to 54). Post-void dribbling or diminished ejaculation did not occur i n any patient, and radiographic studies failed to show recurrent strictures or weakening of the grafted areas after a mean interval of 35.8 months. In the entire Series further dilatation or intervention was not necessary. DISCUSSION
The primary indication for use of dorsal free patch urethroplasty for strictures of the penile urethra is a lesion longer than 1 cm. when end-to-end anastomosis can cause chordee." Contraindications are extensive spongiofibrosis causing almost complete obliteration of the urethral lumen, since opening of the urethra would result in an inadequate surface to be sutured to the dorsal Patch graft, and presence Of chronic infection, either Of the Upper Urinary tract O r locally 'associated bladder and urethral Stones, urethral Pseudodiverticula or fistulas and paraurethral abscesses). The length of the stricture is not a contraindication for this Procedure. The indication for strictures of the bulbous urethra is a lesion longer than 2 cm. when removal of the mucosal lining and surrounding spongiolysis is required. Tubularized free grafts were initially used for losses of urethral continuity greater than 3 cm. but recently dorsal free patch graft urethroplasty also has been used for long strictures with good results (fig. 3). The former procedure is technically more complex, and more often presents postoperative Problems and less satisfactory functional outcome as documented in our earlier experience. From a technical point of view dorsal free graft urethro-
plasty is easier to perform than pedicled graft urethroplasty.13-15 We believe that a dorsally placed patch or tube free graft results in a lower incidence of necrosis as opposed to a ventral patch, since it receives better mechanical support and adequate vascular supply. We also believe that a dorsal graft produces better results than a pedicled ventral graft, since there is less extensive degloving of the penis, no ventral weakening due to formation of urethrocele and, even if a patch graft should necrose, the urethral mucosa regenerates according to the principles of Brownes and Monseurg provided that a catheter is left indwelling for sufficient time. In regard to strictures of the bulbous urethra, the dorsal approach to the diseased segment requires a less extensive openingof the spongy tissue, since the urethral lumen is dorsally located. With this approach bleeding from the corpus spongiosum is considerably reduced and mechanical weakening is virtually impossible. menpedicled grafts are applied to the bulbous urethra with a ventral approach, the extensively incised corpus spongiosum cannot be reapproximated Over them and, in fact, a relatively high incidence of pseudo-diverticula, whose size is sometimes considerable,16. 17 has been documented,6 The results of 2 series of pedicled graft urethroplasty and 2 series of free full thickness graft urethroplasty are shown in the table. The complication rate r a g e d from 3 to 25% and the reoperation rate ranged from 2 to 8%.1S-z0 Although our series is too small and followup is relatively short, to date there have been no significant complications and reintervention has not been required. CONCLUSIONS
me radiological
and findings of 25 who underwent dorsal free graft urethroplasty with a mean followup of 35.8 months indicate that this procedure not only maintains urethral patency but also avoids graft weakening, which has been documented in ventral free or pedicled graft urethroplasty. Therefore, we believe that the use of free skin grafts for strictures of the penile or bulbous urethra is ariatomically healthier in the dorsal than in the ventral position. REFERENCES
1. Webster, G.D.and mow,J. M.: Urethral stricture disease. In: Clinical Urology. Edited by R. J. Krane, M. B. Siroky and J. M. Fitzpatrick. Philadelphia: J. B. Lippincott Co., pp. 906-924, 1994. 2. Keating, M. A., Cartwright, P. C. and Duckett, J. W.: Bladder mucosa in urethral reconstructions. J. Urol., 144: 827, 1990. 3. Burger, R.A,, Muller, S. C., El-Damanhoury,H., Tschakaloff,A., Riedmiller, H. and Hohenfellner, R.: The buccal mucosal gr& for urethral reconstruction:a preliminary report. J. Urol., 1 4 2 662, 1992.
126
DORSAL FREE GRAFT URETHROPLASTY
4. McAniich, J. W.: Reconstruction of extensive urethral strictures: circular fasciocutaneous penile flap. J. Urol., 149: 488, 1993. 5. Webster, G.D., Brown, M.W., Koefoot, R. B., Jr. and Sihelnick, S.: Suboptimal results in full thickness graft urethroplasty using an extrapenile skin donor site. J. Urol., 131: 1082,1984. 6. Webster, G. D. and Robertson, C. N.:The vascularized skin island urethroplasty: its role and results in urethral stricture management. J. Urol., 133:31, 1985. 7. Turner-Warwick, R.: Principles of urethral reconstruction. In: Reconstructive Urology. Edited by G. D. Webster, R. Kirby, L. King and B. Goldwasser. Boston: Blackwell Scientific F'ublications, vol. 2,pp. 609-642, 1993. 8. Browne, D.: Operation for hypospadias. Proc. Roy. Soc. Med., 42: 466, 1949. 9. Monseur, J.: L'elargissement de l ' d t r e au moyen du plan sus uretral. Bilan a p d s 13 an6 sur 219 cas.J. d'urol., 6:439,1980. 10. Devine, P. C.,Wendelken, J. R. and Devine, C. J., Jr.: Free full thickness skin graft urethroplasty: current technique. J. Urol., 121: 282, 1979. 11. Barbagli, G., Menchi, I., Amorosi, A., Selli, C. and Azzaro, F.: Bacteriologic, histologic and ultrasonographic findings in
strictures recurring after urethrotomy: a preliminary study.
Scand. J. Urol. Nephrol., 29: 193, 1995. 12. Webster, G.D.:Personal communication. 13. Orandi, A: One-stage urethroplasty. Brit. J. Urol., 40: 717,1968. 14. Duckett, J. W., Jr.: Transverse preputial island flap technique for repair of severe hypospadias. Urol. Clin. N. Amer., 7: 423, 1980. 15. Quartey, J. K. M.: One-stage peddpreputial island flap ur+ throplasty for urethral stricture. J. Urol., 134.474, 1985. 16. Brigman, G. A. and Deture, F. A.: Giant urethral diverticulum &r free full thickness skin graft urethroplasty. J. Urol., 121: 523,1979. 17. Blum, J. A,Feeney, M. J., Howe, G. E. and Steel, J. F.: Skin patch urethroplasty: 5-year followup. J. Urol., 127: 909,1982. 18. Mundy, A. R. and Stephenson, T. P.: Pedicled preputial patch urethroplasty. Brit. J. Urol., 61: 48, 1988. 19. 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., 116 677,1976. 20. Devine, P. C., Fallon, B. and Devine, C. J., Jr.: Free full thick. ness skin graft urethroplasty. J. Urol., 116 444, 1976.