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Patch Graft Urethroplasty: A Review with Emphasis On Use for Strictures in the Region of the Membranous Urethra
Vol. 115, February
THE JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
PATCH GRAFT URETHROPLASTY: A REVIEW WITH EMPHASIS ON USE FOR STRICTURES IN THE REGION OF THE MEMBRANOUS URETHRA RICHARD G. KIBBEY, III* From the Division of Urology, The University of Texas, Southwestern Medical School at Dallas, Dallas, Texas
ABSTRACT
A series of 40 patch graft urethroplasties is presented. The surgical technique, versatility of the procedure and its application to repair of strictures in the membranous urethra are discussed. Patch graft urethroplasty is a recognized method of management of urethral strictures that is increasing in popularity. Previously, it has been used primarily for short bulbous and pendulous urethral strictures with uniformly good results.,_. This series of 40 urethroplasties confirms these good results and emphasizes some aspects of patch graft urethroplasty that heretofore may have been overlooked. TECHNIQUE
Patients are placed in the lithotomy position except for those with distal urethral strictures, in which case the patient is supine. Methylene blue is injected routinely into the urethral lumen to demonstrate the lumen of the stricture and to identify the mucosal margins. A midline incision is made for proximal and mid urethral strictures. A circumferential incision just proximal to the glans is made and the skin is retracted in a sleeve fashion for distal strictures. A large van Buren sound is passed to the level of the stricture and the urethra is exposed. The urethra is entered distal to the stricture and a filiform is passed through the stricture. The stricture is then incised throughout its length and into the normal proximal urethra. To prevent the stricture from recurring at the proximal or distal extent of the urethroplasty the repair should extend at least 1 cm. into the normal urethra in either direction. A pattern is then cut from the foil backing of a suture package and trimmed to appropriate size. The pattern is placed against the stretched penile skin and outlined with a marking pen. A full thickness graft is then sharply taken at the junction of the dermis and subcutaneous tissue. The full thickness graft is used because graft contraction is minimal compared to the significant degree of contraction associated with split thickness grafts.' Nevertheless, the graft should be 10 to 15 per cent larger than the measured requirement of skin. The graft must be meticulously defatted since fat-like hematoma and suppuration prevent the vascularization of a free graft. Defatting is facilitated by securing the graft, epithelial surface down, to a sterile plastic sheet (dermacarriers IIt) with 25 gauge needles. Then while the graft is kept moistened with saline the excess subcutaneous tissue is excised (fig. 1). An interrupted 4 or 5-zero polyglycolic acid suture (dexon:j:) is used for the mucosa-epithelial anastomosis. When not obliterated by fibrosis the corpus spongiosum and bulbocavernosus muscle are closed as separate layers to support the urethra and to prevent diverticulum formation. Even when moderately scarred the corpus spongiosum can usually be approximated without narrowing the lumen by suturing only the most superficial spongy tissue. A silastic Accepted for publication July 3, 1975. * Current address: 6111 Amarillo Blvd. W., Amarillo, Texas 79106. t Zimmer, Warsaw, Indiana 46580. :j:Davis and Geck, Pearl River, New York 10965.
Foley catheter of appropriate size, usually 24F in adults and 14 to 16F in children, is left in the urethra for 2 weeks. When the catheter is removed a voiding cystourethrogram is performed. If any extravasation is detected a smaller catheter is reinserted for another week. Subsequently, patients are followed with urinalysis, voiding cystourethrograms and urethrograms. Routine calibration is not performed. Occasionally, cystourethroscopy has been performed many months postoperatively, at which time the area of the patch graft has been indistinguishable from the normal urethral mucosa except in 1 black male subject in whom a slight increase in pigmentation was noted in the patch area. RESULTS
Since 1972, 40 patch graft urethroplasties have been performed on 38 patients, ranging in age from 7 to 81 years. Followup has been from 1 to 5 months in 26 cases, 6 to 11 months in 6 and 12 to 24 months in 8. There have been 3 failures. One immediate postoperative failure occurred when a hemolytic crisis complicated by periurethral infection developed in a child with sickle cell disease. Another failure occurred in a black male patient with previous evidence of keloid formation in other surgical scars. Recurrent stricture developed at the proximal and distal limits of the urethroplasty in this case. Both patients subsequently had repeat patch graft urethroplasty and have good results at 14 and 4 months, respectively. In the third patient a periurethral infection developed immediately postoperatively and the patient underwent drainage and suprapubic cystostomy. He will probably require another procedure. Of the remaining patients none has required dilatation or further surgical treatment. DISCUSSION
Patch graft urethroplasty as originally described by Devine and associates has proved to be a highly successful method of
156
KIBBEY
FIG. 2. Nine-year-old child. A, preoperative retrograde urethrogram. B, preoperative voiding cystourethrogram. C, 18-month postoperative voiding cystourethrogram.
FIG. 3. A, preoperative retrograde urethrogram. B, postoperative voiding cystourethrogram
PATC~ GRAFT URETHROPLASTY
FIG. 4. A, retrograde urethrogram. B, 6-month postoperative voiding cystourethrogram
FIG. 5. A, retrograde urethrogram. B, 6-month postoperative voiding cystourethrogram
handling short urethral strictures but indications for its use may be increasing. In our series it has been used for strictures at all points in the urethra distal to the verumontanum. Although not always practical any length stricture could be managed in this fashion, our longest being 15 cm. It has not been necessary to resort to a graft donor site other than the prepuce or shaft skin. A distal penile circumferential graft can generally be obtained even in the circumcised patient owing to the elasticity of the penile skin. In fact both failures in our series also had their second patch graft taken from the penis. Two patients had 2 patches placed simultaneously for 2 separate strictures. Patch graft urethroplasty is a satisfactory method of management of urethral strictures in children since it has been shown that grafts so used will grow with the patient. 5 Of the 38 patients in this series 10 were children, ranging in age from 7 to 16 years. Five children were 9 years old or less (fig. 2). The most recent and perhaps most significant application of the patch graft is for strictures in the region of the membranous urethra previously managed by scrotal or perinea! inlays in 2 stages.•-• Six such strictures have been treated successfully with a transsphincteric patch graft inlay. The strictures usually involved the deep bulb with diseased urethra extending proximally into the membranous urethra, necessitating extension of the to or distal to the verumontanum 3
to 5). The incision is midline (fig. 6, A). As in any repair in the region of the membranous urethra the deep sutures are placed first. Turner-Warwick needles are extremely helpful for placing these initial 3 to 5-zero sutures. Securing the graft to a sterile plastic sheet with 25 gauge needles will allow proper orientation of the graft while sutures are being placed (fig. 6, B). Once the proximal bulb sutures are in place the catheter can be passed per urethram into the bladder and the remainder of the patch is sutured (fig. 6, C and D). The advantages of this approach for strictures in this region are obvious. The procedure is completed in 1 stage without frequent revisions. Repair in 1 stage also allows precise identification and closure of the corpus spongiosum and bulbocavernosus muscle as well as preserves layers, thus, increasing the likelihood of a good functional repair. Finally, should failure occur correction can be accomplished in 1 rather than 2 stages. CONCLUSIONS
Patch graft urethroplasty, originally described for surgical management of selected short urethral strictures, is finding increased use in the management of stricture disease. It is not a panacea and good judgment is required in selection of candidates. However, in view of consistently good results with strictures in a wide of locations, lengths and age groups
158
KIBBEY
FIG. 6
perhaps greater consideration should be given to this 1 stage procedure. In particular this is an appealing alternative for the often difficult stricture in the membranous urethra. REFERENCES
1. 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. 2. 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. 3. Brannan, W., Ochsner, M. G. and Fuselier, H. A., Jr.: Anterior urethral strictures: experience with free graft urethroplasty. J. Urol., 109: 265, 1973. 4. Abrahams, J. I., Patil, U. B., Hackett, R. E., Peng, B. K. and Waterhouse, R. K.: Treatment of urethral stricture by free full-thickness skin graft (Devine) urethroplasty. Urology, 1: 93, 1973. 5. McCormack, R. M.: Simultaneous chordee repair and urethral
reconstruction for hypospadias; experimental and clinical studies. Plast. Reconstr. Surg., 13: 257, 1954. 6. Turner-Warwick, R.: The repair of urethral strictures in the region of the membranous urethra. J. Urol., 100: 303, 1968. 7. Johanson, B.: Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technique. Acta Chir. Scand., suppl. 176, p. 3, 1953. 8. Leadbetter, G. W., Jr.: A simplified urethroplasty for strictures of the bulbous urethra. J. Urol., 83: 54, 1960. COMMENT Surgical repair of urethral strictures by patch graft, as originally described by Devine, is now well accepted. Our experience with this technique for long strictures and for strictures in the membranous urethra has not been as successful as the results reported herein. This form of 1 stage urethroplasty requires the meticulous surgical technique described in this pa per.
Martin G. McLaughlin The Johns Hopkins Hospital Baltimore, Maryland
THE JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
PATCH GRAFT URETHROPLASTY: A REVIEW WITH EMPHASIS ON USE FOR STRICTURES IN THE REGION OF THE MEMBRANOUS URETHRA RICHARD G. KIBBEY, III* From the Division of Urology, The University of Texas, Southwestern Medical School at Dallas, Dallas, Texas
ABSTRACT
A series of 40 patch graft urethroplasties is presented. The surgical technique, versatility of the procedure and its application to repair of strictures in the membranous urethra are discussed. Patch graft urethroplasty is a recognized method of management of urethral strictures that is increasing in popularity. Previously, it has been used primarily for short bulbous and pendulous urethral strictures with uniformly good results.,_. This series of 40 urethroplasties confirms these good results and emphasizes some aspects of patch graft urethroplasty that heretofore may have been overlooked. TECHNIQUE
Patients are placed in the lithotomy position except for those with distal urethral strictures, in which case the patient is supine. Methylene blue is injected routinely into the urethral lumen to demonstrate the lumen of the stricture and to identify the mucosal margins. A midline incision is made for proximal and mid urethral strictures. A circumferential incision just proximal to the glans is made and the skin is retracted in a sleeve fashion for distal strictures. A large van Buren sound is passed to the level of the stricture and the urethra is exposed. The urethra is entered distal to the stricture and a filiform is passed through the stricture. The stricture is then incised throughout its length and into the normal proximal urethra. To prevent the stricture from recurring at the proximal or distal extent of the urethroplasty the repair should extend at least 1 cm. into the normal urethra in either direction. A pattern is then cut from the foil backing of a suture package and trimmed to appropriate size. The pattern is placed against the stretched penile skin and outlined with a marking pen. A full thickness graft is then sharply taken at the junction of the dermis and subcutaneous tissue. The full thickness graft is used because graft contraction is minimal compared to the significant degree of contraction associated with split thickness grafts.' Nevertheless, the graft should be 10 to 15 per cent larger than the measured requirement of skin. The graft must be meticulously defatted since fat-like hematoma and suppuration prevent the vascularization of a free graft. Defatting is facilitated by securing the graft, epithelial surface down, to a sterile plastic sheet (dermacarriers IIt) with 25 gauge needles. Then while the graft is kept moistened with saline the excess subcutaneous tissue is excised (fig. 1). An interrupted 4 or 5-zero polyglycolic acid suture (dexon:j:) is used for the mucosa-epithelial anastomosis. When not obliterated by fibrosis the corpus spongiosum and bulbocavernosus muscle are closed as separate layers to support the urethra and to prevent diverticulum formation. Even when moderately scarred the corpus spongiosum can usually be approximated without narrowing the lumen by suturing only the most superficial spongy tissue. A silastic Accepted for publication July 3, 1975. * Current address: 6111 Amarillo Blvd. W., Amarillo, Texas 79106. t Zimmer, Warsaw, Indiana 46580. :j:Davis and Geck, Pearl River, New York 10965.
Foley catheter of appropriate size, usually 24F in adults and 14 to 16F in children, is left in the urethra for 2 weeks. When the catheter is removed a voiding cystourethrogram is performed. If any extravasation is detected a smaller catheter is reinserted for another week. Subsequently, patients are followed with urinalysis, voiding cystourethrograms and urethrograms. Routine calibration is not performed. Occasionally, cystourethroscopy has been performed many months postoperatively, at which time the area of the patch graft has been indistinguishable from the normal urethral mucosa except in 1 black male subject in whom a slight increase in pigmentation was noted in the patch area. RESULTS
Since 1972, 40 patch graft urethroplasties have been performed on 38 patients, ranging in age from 7 to 81 years. Followup has been from 1 to 5 months in 26 cases, 6 to 11 months in 6 and 12 to 24 months in 8. There have been 3 failures. One immediate postoperative failure occurred when a hemolytic crisis complicated by periurethral infection developed in a child with sickle cell disease. Another failure occurred in a black male patient with previous evidence of keloid formation in other surgical scars. Recurrent stricture developed at the proximal and distal limits of the urethroplasty in this case. Both patients subsequently had repeat patch graft urethroplasty and have good results at 14 and 4 months, respectively. In the third patient a periurethral infection developed immediately postoperatively and the patient underwent drainage and suprapubic cystostomy. He will probably require another procedure. Of the remaining patients none has required dilatation or further surgical treatment. DISCUSSION
Patch graft urethroplasty as originally described by Devine and associates has proved to be a highly successful method of
156
KIBBEY
FIG. 2. Nine-year-old child. A, preoperative retrograde urethrogram. B, preoperative voiding cystourethrogram. C, 18-month postoperative voiding cystourethrogram.
FIG. 3. A, preoperative retrograde urethrogram. B, postoperative voiding cystourethrogram
PATC~ GRAFT URETHROPLASTY
FIG. 4. A, retrograde urethrogram. B, 6-month postoperative voiding cystourethrogram
FIG. 5. A, retrograde urethrogram. B, 6-month postoperative voiding cystourethrogram
handling short urethral strictures but indications for its use may be increasing. In our series it has been used for strictures at all points in the urethra distal to the verumontanum. Although not always practical any length stricture could be managed in this fashion, our longest being 15 cm. It has not been necessary to resort to a graft donor site other than the prepuce or shaft skin. A distal penile circumferential graft can generally be obtained even in the circumcised patient owing to the elasticity of the penile skin. In fact both failures in our series also had their second patch graft taken from the penis. Two patients had 2 patches placed simultaneously for 2 separate strictures. Patch graft urethroplasty is a satisfactory method of management of urethral strictures in children since it has been shown that grafts so used will grow with the patient. 5 Of the 38 patients in this series 10 were children, ranging in age from 7 to 16 years. Five children were 9 years old or less (fig. 2). The most recent and perhaps most significant application of the patch graft is for strictures in the region of the membranous urethra previously managed by scrotal or perinea! inlays in 2 stages.•-• Six such strictures have been treated successfully with a transsphincteric patch graft inlay. The strictures usually involved the deep bulb with diseased urethra extending proximally into the membranous urethra, necessitating extension of the to or distal to the verumontanum 3
to 5). The incision is midline (fig. 6, A). As in any repair in the region of the membranous urethra the deep sutures are placed first. Turner-Warwick needles are extremely helpful for placing these initial 3 to 5-zero sutures. Securing the graft to a sterile plastic sheet with 25 gauge needles will allow proper orientation of the graft while sutures are being placed (fig. 6, B). Once the proximal bulb sutures are in place the catheter can be passed per urethram into the bladder and the remainder of the patch is sutured (fig. 6, C and D). The advantages of this approach for strictures in this region are obvious. The procedure is completed in 1 stage without frequent revisions. Repair in 1 stage also allows precise identification and closure of the corpus spongiosum and bulbocavernosus muscle as well as preserves layers, thus, increasing the likelihood of a good functional repair. Finally, should failure occur correction can be accomplished in 1 rather than 2 stages. CONCLUSIONS
Patch graft urethroplasty, originally described for surgical management of selected short urethral strictures, is finding increased use in the management of stricture disease. It is not a panacea and good judgment is required in selection of candidates. However, in view of consistently good results with strictures in a wide of locations, lengths and age groups
158
KIBBEY
FIG. 6
perhaps greater consideration should be given to this 1 stage procedure. In particular this is an appealing alternative for the often difficult stricture in the membranous urethra. REFERENCES
1. 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. 2. 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. 3. Brannan, W., Ochsner, M. G. and Fuselier, H. A., Jr.: Anterior urethral strictures: experience with free graft urethroplasty. J. Urol., 109: 265, 1973. 4. Abrahams, J. I., Patil, U. B., Hackett, R. E., Peng, B. K. and Waterhouse, R. K.: Treatment of urethral stricture by free full-thickness skin graft (Devine) urethroplasty. Urology, 1: 93, 1973. 5. McCormack, R. M.: Simultaneous chordee repair and urethral
reconstruction for hypospadias; experimental and clinical studies. Plast. Reconstr. Surg., 13: 257, 1954. 6. Turner-Warwick, R.: The repair of urethral strictures in the region of the membranous urethra. J. Urol., 100: 303, 1968. 7. Johanson, B.: Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technique. Acta Chir. Scand., suppl. 176, p. 3, 1953. 8. Leadbetter, G. W., Jr.: A simplified urethroplasty for strictures of the bulbous urethra. J. Urol., 83: 54, 1960. COMMENT Surgical repair of urethral strictures by patch graft, as originally described by Devine, is now well accepted. Our experience with this technique for long strictures and for strictures in the membranous urethra has not been as successful as the results reported herein. This form of 1 stage urethroplasty requires the meticulous surgical technique described in this pa per.
Martin G. McLaughlin The Johns Hopkins Hospital Baltimore, Maryland