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END-TO-END RECONSTRUCTION OF SYNCHRONOUS URETHRAL STRICTURES
0022-5347/02/1673-1389/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 167, 1389, March 2002 Printed in U.S.A.
END-TO-END RECONSTRUCTION OF SYNCHRONOUS URETHRAL STRICTURES BRIAN J. DeCASTRO, SHANE B. ANDERSON
AND
ALLEN F. MOREY*
From the Urology Service, Brooke Army Medical Center, San Antonio, Texas KEY WORDS: urethral stricture; anastomosis, surgical
To our knowledge we report the first case of single stage end-to-end reconstruction of synchronous urethral strictures. CASE REPORT
A 48-year-old man presented with decreased force of urinary stream 16 months after a 4 cm. bulbous urethral stricture had been reconstructed with a buccal mucosal graft onlay. Radiographic evaluation demonstrated that the stricture had recurred at the distal end of the graft (fig. 1). Primary end-to-end urethroplasty was planned. The urethra was amputated at the site of the distal bulbar stenosis, which was completely excised. Calibration of the proximal segment revealed a dense second stricture at the bulbomembranous junction. Reconstruction of the distal stricture was completed via a spatulated tension-free 2-layer anastomosis after the normal distal urethra was mobilized to the penoscrotal junction. The catheter was advanced about 5 cm. beyond the anastomosis to the site of the bulbo-membranous stricture, which was then also completely excised in conjunction with a second end-to-end reconstruction. During the proximal repair the intervening segment of bulbous urethra was noted to be bleeding normally. The patient recovered well, and a postoperative voiding cystourethrogram demonstrated a widely patent bulbar urethra (fig. 2). The patient remained asymptomatic at 9-month followup.
FIG. 2. Postoperative voiding cystourethrogram demonstrates patent bulbar urethra (arrows).
DISCUSSION
Stricture excision with primary end-to-end anastomosis is the ideal treatment for short dense anterior urethral stricAccepted for publication October 19, 2001. * Financial interest and/or other relationship with Pfizer and Ortho-McNeil.
tures.1, 2 To our knowledge there have been no documented cases of synchronous strictures managed entirely by end-toend urethroplasty. Patients with multiple strictures have been managed with end-to-end anastomosis of the proximal stricture and simultaneous use of a flap or graft onlay technique for the more distal stricture. The dual blood supply of the corpus spongiosum promotes viability of the anterior urethra after complete transection. The proximal urethral segment is supplied by the bulbourethral artery. The distal urethra is supplied by retrograde flow of blood from the dorsal and corporeal arteries via the glans penis.3 It has been speculated that a second transection of the anterior urethra would leave an intervening segment of the urethra without adequate vascularity, which might be prone to ischemic stricture formation. In our case a 2-layer anastomotic technique was used twice, thus preserving the rich vascularity of the intervening corpus spongiosum. This case suggests that end-to-end anastomosis may be useful for single stage reconstruction of synchronous strictures. Long-term followup is needed to determine the durability and reproducibility of this approach. REFERENCES
FIG. 1. Preoperative voiding cystourethrogram shows synchronous short bulbar strictures (arrows). 1389
1. Martinez-Pineiro, J. A., Carcamo, P., Garcia Matres, M. J. et al: Excision and anastomotic repair for urethral stricture disease: experience with 150 cases. Eur Urol, 32: 433, 1997 2. Rosen, M. A. and McAninch, J. W.: Stricture excision and primary anastomosis for reconstruction of the anterior urethral stricture. In: Traumatic and Reconstructive Urology. Edited by J. W. McAninch and R. Zorab. Philadelphia: W. B. Saunders Co., chapt. 47, pp. 565–569, 1996 3. Wessells, H., Morey, A. F. and McAninch, J. W.: Single stage reconstruction of complex anterior urethral strictures: combined tissue transfer techniques. J Urol, 157: 1271, 1997
Vol. 167, 1389, March 2002 Printed in U.S.A.
END-TO-END RECONSTRUCTION OF SYNCHRONOUS URETHRAL STRICTURES BRIAN J. DeCASTRO, SHANE B. ANDERSON
AND
ALLEN F. MOREY*
From the Urology Service, Brooke Army Medical Center, San Antonio, Texas KEY WORDS: urethral stricture; anastomosis, surgical
To our knowledge we report the first case of single stage end-to-end reconstruction of synchronous urethral strictures. CASE REPORT
A 48-year-old man presented with decreased force of urinary stream 16 months after a 4 cm. bulbous urethral stricture had been reconstructed with a buccal mucosal graft onlay. Radiographic evaluation demonstrated that the stricture had recurred at the distal end of the graft (fig. 1). Primary end-to-end urethroplasty was planned. The urethra was amputated at the site of the distal bulbar stenosis, which was completely excised. Calibration of the proximal segment revealed a dense second stricture at the bulbomembranous junction. Reconstruction of the distal stricture was completed via a spatulated tension-free 2-layer anastomosis after the normal distal urethra was mobilized to the penoscrotal junction. The catheter was advanced about 5 cm. beyond the anastomosis to the site of the bulbo-membranous stricture, which was then also completely excised in conjunction with a second end-to-end reconstruction. During the proximal repair the intervening segment of bulbous urethra was noted to be bleeding normally. The patient recovered well, and a postoperative voiding cystourethrogram demonstrated a widely patent bulbar urethra (fig. 2). The patient remained asymptomatic at 9-month followup.
FIG. 2. Postoperative voiding cystourethrogram demonstrates patent bulbar urethra (arrows).
DISCUSSION
Stricture excision with primary end-to-end anastomosis is the ideal treatment for short dense anterior urethral stricAccepted for publication October 19, 2001. * Financial interest and/or other relationship with Pfizer and Ortho-McNeil.
tures.1, 2 To our knowledge there have been no documented cases of synchronous strictures managed entirely by end-toend urethroplasty. Patients with multiple strictures have been managed with end-to-end anastomosis of the proximal stricture and simultaneous use of a flap or graft onlay technique for the more distal stricture. The dual blood supply of the corpus spongiosum promotes viability of the anterior urethra after complete transection. The proximal urethral segment is supplied by the bulbourethral artery. The distal urethra is supplied by retrograde flow of blood from the dorsal and corporeal arteries via the glans penis.3 It has been speculated that a second transection of the anterior urethra would leave an intervening segment of the urethra without adequate vascularity, which might be prone to ischemic stricture formation. In our case a 2-layer anastomotic technique was used twice, thus preserving the rich vascularity of the intervening corpus spongiosum. This case suggests that end-to-end anastomosis may be useful for single stage reconstruction of synchronous strictures. Long-term followup is needed to determine the durability and reproducibility of this approach. REFERENCES
FIG. 1. Preoperative voiding cystourethrogram shows synchronous short bulbar strictures (arrows). 1389
1. Martinez-Pineiro, J. A., Carcamo, P., Garcia Matres, M. J. et al: Excision and anastomotic repair for urethral stricture disease: experience with 150 cases. Eur Urol, 32: 433, 1997 2. Rosen, M. A. and McAninch, J. W.: Stricture excision and primary anastomosis for reconstruction of the anterior urethral stricture. In: Traumatic and Reconstructive Urology. Edited by J. W. McAninch and R. Zorab. Philadelphia: W. B. Saunders Co., chapt. 47, pp. 565–569, 1996 3. Wessells, H., Morey, A. F. and McAninch, J. W.: Single stage reconstruction of complex anterior urethral strictures: combined tissue transfer techniques. J Urol, 157: 1271, 1997