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Repair of the Recurrent Fistula of the Penile Urethra
Vol. 106, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
REPAIR OF THE RECURRENT FISTULA OF THE PENILE URETHRA MAXWELL MALAMENT
From the Urological Section, Surgical Service, Veterans Administration Hospital, East Orange, and the College of Medicine and Dentistry of New Jersey, Newark, New Jersey
Prolonged bladder drainage of the cord injury patient with an indwelling urethral catheter is associated with numerous complications. The penoscrotal junction is commonly involved since urethritis and mucosal ulceration favor development of a periurethral abscess. When the abscess ruptures into the urethral lumen a diverticulum remains but when the abscess perforates through the skin a urethrocutaneous fistula results. The incidence of urethral fistula formation is 6.5 per cent in the cord injury patient.1 The early treatment of the penoscrotal fistula is conservative and, with the aid of antibiotics, urethral irrigations, attachment of the penis to the abdomen with tape and adoption of narrow gauge plastic tubing for urinary drainage, primary closure may occur. Comarr reported a 35 per cent incidence of spontaneous healing following conservative therapy. 2 Persistence of the fistula is an indication for urinary diversion preferably by perineal urethrostomy. Spontaneous closure of the fistula is not uncommon after urinary diversion but when the sinus tract remains patent surgical repair is necessary. The success of an operation has averaged 35 per cent at the first attempt. Failure has been due to the fact that the tissues involved in the repair are neurotrophic, infected and poorly vascularized. Bunts reported on 61 procedures to close 22 urethral fistulas. 1 Surgical variations in technique have not improved the results greatly. Two cord bladder patients had several unsuccessful procedures for repair of a urethral fistula. A 2-stage surgical modification was evolved, incorporating the principles of Denis Browne in the development of a tube from a buried strip of epithelial-lined tissue. This procedure was performed successfully on 3 occasions in 2 patients. Accepted for publication December 1970. 1 Bunts, R. C.: Management of urological complications in 1,000 paraplegics. J. Urol., 79: 733, 1958. 2 Comarr, A. E.: Management of penoscrotal fistulas and/or diverticula. J. Urol., 84: 490, 1960.
TECHNIQUE
An incision is made around the urethrocutaneous fistula and the scarred edges are excised (fig. 1). Dissection is continued by separating the skin and Colles' fascia from the urethra. A longitudinal skin incision, which is equal in length to the urethral defect, is made over the anterior surface of the scrotum. The area selected must be easily placed in apposition to the urethral sinus. The scrotal skin incision is carried down to the tunica dartos fascia and then dissected laterally about 1.5 cm. on each side. The urethral rim is sutured to the lateral aspect of the tunica dartos with interrupted sutures of 4-zero chromic catgut (fig. 2). The tunica dartos is separated from the skin in the inferior lateral area to permit the placement of a drain on each side. The penile skin is approximated to the scrotal skin using 4-zero black silk or 5-zero nylon. The drains are removed after 24 to 48 hours. The penis should be released from the scrotum in the second stage, which is done 6 to 8 weeks after the first stage. A No. 20 Robinson catheter is inserted into the urethra and left indwelling during the operation. A rectangular skin incision is made, the lateral borders extending 1.5 cm. from the penoscrotal suture line and the horizontal incision remaining level with the distal and proximal penoscrotal attachment (fig. 3). The incision is extended down to the tunica dartos fascia and dissection is continued medially in the same fascial plane, releasing the penis from the scrotum. The indwelling Robinson catheter is used as a guide to avoid entering the newly formed urethral canal. When the penis is separated from the scrotum 2 skin defects are present. The scrotal defect is closed by approximating the skin edges. The penile defect with the exposed tunica dartos fascia as the ventral wall of the urethra is covered by the 2 lateral flaps of scrotal skin. To approximate the skin edges 4-zero black silk is used. A pressure dressing is applied and the penis is taped to the abdomen. 704
REP AIR OF RECURRENT FISTULA OF PENILE URETHRA
Tunica {Parietal Loyer VOqinalis Visceral Layer communis Testis Median Septum
Fro. 1. .A, separation of penile skin from ure-
thral margin. Dotted line over scrotal median raphe indicates area of incision. B, scrotal skin undermined laterally exposing tunica dartos fascia. C, cross section of scrotal operative site shows anatomical details.
705
space to create an epithelial-lined lumen. Epithelialization occutred in 2 weeks and the major circumferential contraction was completed in about 6 weeks. The 2-stage urethroplasty described used the urethral mucosa as the source of epithelial growth over the tunica dartos fascia to form a new urethral lumen. The scrotal skin provides a reinforcing support for the urethral canal. The procedure was successful on 3 occasions in 2 patients. The first case involved a quadriplegic patient who underwent 3 operations to repair an extensive urethral defect at the penoscrotal junction. The extensive scarring and poor vascularization in this patient precluded any further surgical intervention. However, the 2stage urethroplasty was undertaken successfully. The second patient was a paraplegic whose urethral fistula developed secondary to trauma (fig. 4, A). After 2 surgical failures the 2-stage
Fm. 2. .A, appearance of prepared operative areas prior to anastomosis. B, anastomosis of urethral margin to tunica dartos. C, cutaneous approximation of penile and scrotal skin with urethral-dartos anastomosis completed. Note presence of drain site. D, completed first stage of repair with drain extending out of scrotum. E, cross section of operative field indicates appearance of ureteral channel. DISCUSSION
The operative technique incorporates the principles of the Denis Browne urethroplasty described by Nesbit. 3 Experimental animal studies demonstrated that epithelialization from a buried strip of skin extended around a tubular 3 Nesbit, R. M., Butler, W. J. and Whitaker, W.: Production of epithelial lined tubes from buried strips of intact skin. J. Urol., 64: 387, 1950.
technique was completed successfully (fig. 4, B). Fifteen months later this patient returned with another urethral fistula resulting from a constricting band around the penis. The 2-stage urethroplasty was used again with an excellent result. The operation is not recommended as a primary method of repair since the simple repair of a urethral fistula has a 35 per cent initial incidence
706
MALAMENT
A
B Fm. 3. A, cross section reveals line of dissection in second stage. B, lateral view of scrotal rectangular incision. C, illustration of penile and scrotal defects with attached skin flaps to penis following separation of penis from scrotum. D, closure of scrotal defect. E, closure of penile defect by approximation of skin flaps. F, appearance at completion of operation.
Fro. 4. A, urethral defect reveals indwelling catheter. Note circular laceration. B, repaired area 1 month after second stage. of success. However, it should be considered for patients who after several failures have only poorly vascularized fibrotic scarred tissue. The elapse of 6 to 8 weeks between stages allows for collateral blood supply to extend from the scrotal flap to the penile skin. When the penis is separated from the scrotum, the scrotal skin flap
used to cover the newly created urethra is dependent on the penile blood supply. Gentle handling of the tissues is important and small plastic surgical instruments are used. After completion of the first stage, examination of the operative site should be done carefully since forceful manipulation may cause separation of the
REP AIR OF RECURRENT FISTULA OF PENILE URETHRA
suture line. Estrogens and antihistamines are advised to prevent penile erections. Although experience with this procedure is limited, it has been successful and is being presented as another technical modality for the repair of the recurrent urethral fistula. It may be a useful procedure in the repair of the urethral fistula secondary to hypospadias repair.
707
SUMMARY
A 2-stage surgical operation for repair of recurrent fistulas of the penile urethra is described. Indication for its application is the presence of fibrotic scarred tissues with extensive vascular deficit resulting from previous unsuccessful attempts at a reconstructive operation.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
REPAIR OF THE RECURRENT FISTULA OF THE PENILE URETHRA MAXWELL MALAMENT
From the Urological Section, Surgical Service, Veterans Administration Hospital, East Orange, and the College of Medicine and Dentistry of New Jersey, Newark, New Jersey
Prolonged bladder drainage of the cord injury patient with an indwelling urethral catheter is associated with numerous complications. The penoscrotal junction is commonly involved since urethritis and mucosal ulceration favor development of a periurethral abscess. When the abscess ruptures into the urethral lumen a diverticulum remains but when the abscess perforates through the skin a urethrocutaneous fistula results. The incidence of urethral fistula formation is 6.5 per cent in the cord injury patient.1 The early treatment of the penoscrotal fistula is conservative and, with the aid of antibiotics, urethral irrigations, attachment of the penis to the abdomen with tape and adoption of narrow gauge plastic tubing for urinary drainage, primary closure may occur. Comarr reported a 35 per cent incidence of spontaneous healing following conservative therapy. 2 Persistence of the fistula is an indication for urinary diversion preferably by perineal urethrostomy. Spontaneous closure of the fistula is not uncommon after urinary diversion but when the sinus tract remains patent surgical repair is necessary. The success of an operation has averaged 35 per cent at the first attempt. Failure has been due to the fact that the tissues involved in the repair are neurotrophic, infected and poorly vascularized. Bunts reported on 61 procedures to close 22 urethral fistulas. 1 Surgical variations in technique have not improved the results greatly. Two cord bladder patients had several unsuccessful procedures for repair of a urethral fistula. A 2-stage surgical modification was evolved, incorporating the principles of Denis Browne in the development of a tube from a buried strip of epithelial-lined tissue. This procedure was performed successfully on 3 occasions in 2 patients. Accepted for publication December 1970. 1 Bunts, R. C.: Management of urological complications in 1,000 paraplegics. J. Urol., 79: 733, 1958. 2 Comarr, A. E.: Management of penoscrotal fistulas and/or diverticula. J. Urol., 84: 490, 1960.
TECHNIQUE
An incision is made around the urethrocutaneous fistula and the scarred edges are excised (fig. 1). Dissection is continued by separating the skin and Colles' fascia from the urethra. A longitudinal skin incision, which is equal in length to the urethral defect, is made over the anterior surface of the scrotum. The area selected must be easily placed in apposition to the urethral sinus. The scrotal skin incision is carried down to the tunica dartos fascia and then dissected laterally about 1.5 cm. on each side. The urethral rim is sutured to the lateral aspect of the tunica dartos with interrupted sutures of 4-zero chromic catgut (fig. 2). The tunica dartos is separated from the skin in the inferior lateral area to permit the placement of a drain on each side. The penile skin is approximated to the scrotal skin using 4-zero black silk or 5-zero nylon. The drains are removed after 24 to 48 hours. The penis should be released from the scrotum in the second stage, which is done 6 to 8 weeks after the first stage. A No. 20 Robinson catheter is inserted into the urethra and left indwelling during the operation. A rectangular skin incision is made, the lateral borders extending 1.5 cm. from the penoscrotal suture line and the horizontal incision remaining level with the distal and proximal penoscrotal attachment (fig. 3). The incision is extended down to the tunica dartos fascia and dissection is continued medially in the same fascial plane, releasing the penis from the scrotum. The indwelling Robinson catheter is used as a guide to avoid entering the newly formed urethral canal. When the penis is separated from the scrotum 2 skin defects are present. The scrotal defect is closed by approximating the skin edges. The penile defect with the exposed tunica dartos fascia as the ventral wall of the urethra is covered by the 2 lateral flaps of scrotal skin. To approximate the skin edges 4-zero black silk is used. A pressure dressing is applied and the penis is taped to the abdomen. 704
REP AIR OF RECURRENT FISTULA OF PENILE URETHRA
Tunica {Parietal Loyer VOqinalis Visceral Layer communis Testis Median Septum
Fro. 1. .A, separation of penile skin from ure-
thral margin. Dotted line over scrotal median raphe indicates area of incision. B, scrotal skin undermined laterally exposing tunica dartos fascia. C, cross section of scrotal operative site shows anatomical details.
705
space to create an epithelial-lined lumen. Epithelialization occutred in 2 weeks and the major circumferential contraction was completed in about 6 weeks. The 2-stage urethroplasty described used the urethral mucosa as the source of epithelial growth over the tunica dartos fascia to form a new urethral lumen. The scrotal skin provides a reinforcing support for the urethral canal. The procedure was successful on 3 occasions in 2 patients. The first case involved a quadriplegic patient who underwent 3 operations to repair an extensive urethral defect at the penoscrotal junction. The extensive scarring and poor vascularization in this patient precluded any further surgical intervention. However, the 2stage urethroplasty was undertaken successfully. The second patient was a paraplegic whose urethral fistula developed secondary to trauma (fig. 4, A). After 2 surgical failures the 2-stage
Fm. 2. .A, appearance of prepared operative areas prior to anastomosis. B, anastomosis of urethral margin to tunica dartos. C, cutaneous approximation of penile and scrotal skin with urethral-dartos anastomosis completed. Note presence of drain site. D, completed first stage of repair with drain extending out of scrotum. E, cross section of operative field indicates appearance of ureteral channel. DISCUSSION
The operative technique incorporates the principles of the Denis Browne urethroplasty described by Nesbit. 3 Experimental animal studies demonstrated that epithelialization from a buried strip of skin extended around a tubular 3 Nesbit, R. M., Butler, W. J. and Whitaker, W.: Production of epithelial lined tubes from buried strips of intact skin. J. Urol., 64: 387, 1950.
technique was completed successfully (fig. 4, B). Fifteen months later this patient returned with another urethral fistula resulting from a constricting band around the penis. The 2-stage urethroplasty was used again with an excellent result. The operation is not recommended as a primary method of repair since the simple repair of a urethral fistula has a 35 per cent initial incidence
706
MALAMENT
A
B Fm. 3. A, cross section reveals line of dissection in second stage. B, lateral view of scrotal rectangular incision. C, illustration of penile and scrotal defects with attached skin flaps to penis following separation of penis from scrotum. D, closure of scrotal defect. E, closure of penile defect by approximation of skin flaps. F, appearance at completion of operation.
Fro. 4. A, urethral defect reveals indwelling catheter. Note circular laceration. B, repaired area 1 month after second stage. of success. However, it should be considered for patients who after several failures have only poorly vascularized fibrotic scarred tissue. The elapse of 6 to 8 weeks between stages allows for collateral blood supply to extend from the scrotal flap to the penile skin. When the penis is separated from the scrotum, the scrotal skin flap
used to cover the newly created urethra is dependent on the penile blood supply. Gentle handling of the tissues is important and small plastic surgical instruments are used. After completion of the first stage, examination of the operative site should be done carefully since forceful manipulation may cause separation of the
REP AIR OF RECURRENT FISTULA OF PENILE URETHRA
suture line. Estrogens and antihistamines are advised to prevent penile erections. Although experience with this procedure is limited, it has been successful and is being presented as another technical modality for the repair of the recurrent urethral fistula. It may be a useful procedure in the repair of the urethral fistula secondary to hypospadias repair.
707
SUMMARY
A 2-stage surgical operation for repair of recurrent fistulas of the penile urethra is described. Indication for its application is the presence of fibrotic scarred tissues with extensive vascular deficit resulting from previous unsuccessful attempts at a reconstructive operation.