Urethral Reconstruction Using Autologous Vein Grafts for the Management of Urethral Strictures

Refractory Urethral Stricture Management: Indications for Alternative Grafts and Flaps

PURPOSE OF REVIEW

Urethral strictures that are refractory to initial management present unique challenges to the reconstructive surgeon. Treatment trends have shifted as new tissue resources are becoming available. There is renewed interest in old methods as skill and technique have improved. We describe the scope of the surgical armamentarium available to develop creative approaches and successful outcomes.

RECENT FINDINGS

We discuss techniques to maximize the availability of oral mucosa, harvest and use of rectal mucosa, and developments in tissue engineering. Evolving methods to assess success of repair are also described. Urethral reconstruction for refractory urethral strictures requires proficiency with multiple methods as these strictures often require combining techniques for successful treatment.

Looking beyond oral mucosa: Initial results of everted saphenous vein graft urethroplasty (eSVGU) in long anterior urethral strictures

Objective

To prospectively evaluate the feasibility and initial results of an everted saphenous vein graft (eSVG) as a dorsolateral onlay, in patients with long anterior urethral strictures and/or chronic tobacco users.

Patients and methods

In all, 20 patients with long anterior urethral strictures (>7 cm) and/or chronic tobacco exposed oral mucosa were included in the study. The harvested SVG was hydro-distended, detubularised, and everted. Substitution urethroplasty using an eSVG was performed using a dorsolateral onlay technique. Symptoms were assessed using the International Prostate Symptom Score (IPSS) and uroflowmetry at 1, 3 and 6 months; and voiding and retrograde urethrograms, and urethroscopy were done at 3 months. Failure was defined as failure to void, need for interventions in form of direct-vision internal urethrotomy or endodilatation.

Results

Three patients were excluded because they underwent a staged urethroplasty. In all, 17 patients underwent eSVG substitution urethroplasty. The mean (SD, range) follow-up of our patients was 17.64 (5.23, 10–26) months. The mean (SD, range) length of the strictured segment was 14 (2.5, 10–18) cm and the length of the harvested SVG was 16.3 (2.7, 12–20) cm. The mean (SD) IPSS at 1, 3 and 6 months after catheter removal was 10 (2.8), 10 (3.4) and 10 (1.4) and the quality-of-life score was 1.76 (0.5), 2.05 (1.0) and 2.05 (1.0), respectively. Postoperatively, endodilatation was required in two patients. Complete failure occurred in one patient.

Conclusions

An eSVG, as a dorsolateral onlay graft, is a promising and prudent option for long anterior urethral strictures, especially in patients with poor oral hygiene and chronic tobacco use.

Use of a fibrovascular tube in creation of neo-urethra during penile reconstruction

INTRODUCTION

There are several techniques employed in the surgical treatment of total or partial penile reconstruction, hypospadias surgery, and urethral stricture. Urethral reconstruction is performed in different ways applying these techniques.

OBJECTIVE

We evaluated use of a fibrovascular sheath to create a neo-urethra formed around a silicon tube.

MATERIAL AND METHODS

We used nine male New Zealand rabbits for this study. In the first step, we placed a silicone tube under the skin in the lower abdomen of the rabbits and waited for the formation of a fibrovascular sheath to totally surround the tube. In the second step, the silicone tube was removed and the formed fibrovascular sheath was anastomosed with penile urethra over a silicone 8F Foley catheter. Ten days after the second step, the silicone Foley catheter was removed. Twenty days after the second step, we evaluated the newly created neo-urethra with a retrograde urethrogram. Thirty days after the second step, the rabbits were sacrificed and the bladder, urethra, and neo-urethra were removed for histopathological examination.

RESULTS

Six of the rabbits completed the study. After the first operation, in the third month, formation of the fibrovascular sheath was observed around the silicon tube. After anastomosis and removal of the silicon Foley catheter, urine was seen to pass through the neo-urethral meatus. Urethrocystography showed that the neo-urethra and penile urethra were aligned and urine flow was regular. Histopathological evaluation showed that the structural integrity of the newly formed urethra was comparable with the structure of the regular urethra (Table) and the calibration did not change over time, although the newly formed urethra was not covered with uroepithelium.

CONCLUSIONS

In this study, we achieved promising results with use of a newly formed fibrovascular sheath as a neo-urethra.