Single-stage dorsal inlay split-skin graft for salvage anterior urethral reconstruction

Recurrent Anterior Urethral Stricture: Challenges and Solutions

Recurrent male anterior urethral stricture disease is a complex surgical challenge that should be managed by reconstructive urologists with experience in stricture management. Diagnosis of recurrence requires both anatomic narrowing and patient symptoms identified on validated questionnaires, with limited role for intervention in asymptomatic treatment “failures”. Endoscopic management has a very specific role in recurrence, and the choice of technique for urethroplasty depends on pre-operative urethrography and cystoscopy. Surgical success depends on addressing patient concerns, complete stricture excision, tissue quality optimization, and the use of multi-stage repair when indicated. Augmentation with genital skin flaps and/or grafts is often required, with buccal mucosa as the ideal graft source if local tissue is compromised. Salvage options including urinary diversion and perineal urethrostomy must also be considered in debilitated patients with severe disease or repeated treatment failures. Unique patient populations including patients with hypospadias and lichen sclerosis are among the highest risk for repeated recurrence and require special care in surgical technique, graft selection, and post-operative management.

Novel use of Asopa technique for penile urethrocutaneous fistula repair

PURPOSE

To evaluate the feasibility of ventral urethrotomy, dorsal inlay (Asopa) technique in management of urethrocutaneous fistula. The Asopa technique has been employed for management of urethral stricture repair but has not been described in adult penile urethrocutaneous fistula.

METHODS

This is a retrospective review of IRB-approved databases of patients undergoing urethral reconstruction from two urologic reconstruction units. In this technique, the fistulous tract is circumscribed and excised, leaving a larger ventral urethral defect with healthy edges. The ventral-sagittal urethrotomy is extended, a dorsal urethrotomy made, and a graft inlaid dorsally to augment the urethral caliber prior to tension-free closure of the ventral urethrotomy.

RESULTS

From 2010 to 2019, ten patients underwent repair of urethrocutaneous fistula using the Asopa technique. Median patient age was 33.5 years (IQR 35.5). All fistulae involved penile urethra, eight had concomitant adjacent urethral stricture. Five patients failed prior hypospadias repair, three developed fistulae after surgery for penile urethral stricture, and two developed fistulae after extensive debridement (hidradenitis and Fournier's gangrene). Of these ten patients, oral mucosa graft was used in nine and preputial graft in one to augment the urethra. At median follow-up of 50.5 months (IQR 26.5), 80% (8/10) of patients demonstrated durably patent urethra, with no recurrence of fistula.

CONCLUSION

The Asopa technique is an established option for augmenting urethral caliber for urethral stricture disease. We demonstrate in our series that this technique can be applied to patients with urethrocutaneous fistulae.

Dorsal inlay buccal mucosal graft (Asopa) urethroplasty for anterior urethral stricture

Asopa described the inlay of a graft into Snodgrass’s longitudinal urethral plate incision using a ventral sagittal urethrotomy approach in 2001. He claimed that this technique was easier to perform and led to less tissue ischemia due to no need for mobilization of the urethra. This approach has subsequently been popularized among reconstructive urologists as the dorsal inlay urethroplasty or Asopa technique. Depending on the location of the stricture, either a subcoronal circumferential incision is made for penile strictures, or a midline perineal incision is made for bulbar strictures. Other approaches for penile urethral strictures include the non-circumferential penile incisional approach and a penoscrotal approach. We generally prefer the circumferential degloving approach for penile urethral strictures. The penis is de-gloved and the urethra is split ventrally to exposure the stricture. It is then deepened to include the full thickness of the dorsal urethra. The dorsal surface is made raw and grafts are fixed on the urethral surface. Quilting sutures are placed to further anchor the graft. A Foley catheter is placed and the urethra is retubularized in two layers with special attention to the staggering of suture lines. The skin incision is then closed in layers. We have found that it is best to perform an Asopa urethroplasty when the urethral plate is ≥1 cm in width. The key to when to use the dorsal inlay technique all depends on the width of the urethral plate once the urethrotomy is performed, stricture etiology, and stricture location (penile vs. bulb).

Tissue transfer techniques in reconstructive urology

Tissue transfer techniques are an essential part of the reconstructive urologist's armamentarium. Flaps and graft techniques are widely used in genital and urethral reconstruction. A graft is tissue that is moved from a donor site to a recipient site without its native blood supply. The main types of grafts used in urology are full thickness grafts, split thickness skin grafts and buccal mucosa grafts. Flaps are transferred from the donor site to the recipient site on a pedicle containing its native blood supply. Flaps can be classified based on blood supply, elevation methods or the method of transfer. The most used flaps in urology include penile, preputial, and scrotal skin. We review the various techniques used in reconstructive urology and the outcomes of these techniques.

Revision urethroplasty success is comparable to primary urethroplasty: a comparative analysis

OBJECTIVE

To assess the efficacy and complications of revision urethroplasty compared with urethroplasty-naïve controls.

MATERIALS AND METHODS

A retrospective analysis was performed of 534 urethroplasties performed by a single surgeon from August 2003 to March 2011. Patient age, stricture length, location, etiology, comorbidities, and type of surgery were recorded. Statistical comparison between the revision cohort and urethroplasty-naïve group were made using Fisher, χ(2), and unpaired t tests, with significance at P < .05 (2-tailed). The primary outcome was urethral patency assessed by cystoscopy. Secondary (subjective) outcome measures included erectile dysfunction, pain, urinary tract infection, or chordee at 6 months.

RESULTS

A total of 476 patients met inclusion criteria with completed cystoscopic follow-up. Previous urethroplasty had failed in 49 patients (10.3%). Patients undergoing revision urethroplasty were more likely to have stricture in the penile urethra (22.4%; P = .001), to have strictures exceeding 4 cm in length (71.4% vs 54.3%; P = .023), and to require tissue transfer (83.6% vs 65.1%; P = .010). Urethral patency rates did not differ significantly between naïve and revision urethroplasty cohorts, with a mean follow-up of 49.9 months (94.6% vs 91.8%; P = .518). The revision group had a higher incidence of chordee (2.7% vs 14.3%; P = .001) and urinary tract infection (3.5% vs 10.2%; P = .04). The rates of erectile dysfunction, scrotal pain, lower urinary tract symptoms, and incontinence did not differ significantly between the 2 groups.

CONCLUSION

Revision urethroplasty is an effective treatment option for recurrent stricture after urethroplasty and is comparable to results in urethroplasty-naïve patients. Patients undergoing revision urethroplasty are more likely to require tissue transfer and experience higher rates of chordee and urinary tract infection.

Revision of perineal urethrostomy using a meshed split-thickness skin graft

Perineal urethrostomy is considered to be the last option to restore voiding in complex/recurrent urethral stricture disease. It is also a necessary procedure after penectomy or urethrectomy. Stenosis of the perineal urethrostomy has been reported in up to 30% of cases. There is no consensus on how to treat a stenotic perineal urethrostomy, but, in general, a form of urinary diversion is offered to the patient. We present the case of a young male who underwent perineal urethrostomy after urethrectomy for urethral cancer. The postoperative period was complicated by wound dehiscence with subsequent complete obliteration of the perineal urethrostomy. Revision surgery was performed with reopening of the obliterated urethral stump and coverage of the skin defect between the urethra and the perineal/scrotal skin with a meshed split-thickness skin graft. To date, this patient is voiding well and satisfied with the offered solution.

Urethral stricture: etiology, investigation and treatments

BACKGROUND

Urethral stricture is a narrowing of the urethra due to scar tissue, which leads to obstructive voiding dysfunction with potentially serious consequences for the entire urinary tract. Its prevalence among men in industrial countries is estimated at 0.9%. It produces obstructive and irritative urinary symptoms and can ultimately impair renal function. Urethral strictures can be caused by diagnostic or therapeutic urological procedures. These procedures are being performed ever more commonly, because the population is aging; thus, urethral strictures will probably become more common as well.

METHODS

We selectively reviewed pertinent original articles and meta-analyses (1995-2012) on the causes, diagnostic evaluation, and treatment of urethral strictures, which were retrieved by a search in the PubMed database.

RESULTS

Most of the relevant publications are reports of retrospective studies from single centers. Only a few prospective randomized trials and structured reviews are available. The overall level of the scientific evidence is low. 45% of urethral strictures are iatrogenic, 30% idiopathic, and 20% due to bacterial urethritis. Strictures are diagnosed with a flow test and a retrograde urethrogram. Short bulbar strictures can be treated endoscopically. For recurrent and complex strictures, only open urethral surgery can reliably and permanently remove the infravesical obstruction.

CONCLUSION

Urethral strictures must be recognized and treated so that their most serious long-term complication, impaired renal function, can be prevented. The clinical utility of urethrotomy is limited by a high recurrence rate.

About Surgical Correction of Urethral Stenosis: Urethroplasty

Objective

The aim of our study has been to evaluate our results in the treatment of urethral stenosis through several surgical approaches of urethroplasty: the one-stage procedure by direct end-to-end anastomosis, the free dorsal onlay graft urethroplasty using buccal mucosa, and the two-stage urethroplasty.

Methods

Between February 2009 and January 2012, 53 patients were enrolled and analyzed for different types of urethral reconstruction.

Results

The procedures included direct end-to-end anastomosis in 26 patients (49%), 18 (34%) underwent a two-stage urethroplasty (Johansen's), in 9 a free dorsal onlay buccal mucosa urethroplasty was performed. At a mean follow-up of 17 months, we had an overall success rate of 95%. When stratified on the basis of the procedure performed, in the direct end-to-end anastomosis 98% of patients had no evidence of recurrent stricture, 96% of success rate was reached in the onlay buccal mucosa urethroplasty, and 91% in the two-stage procedure.

Conclusions

In patients with urethral strictures, urethroplasty has to be preferred with respect to urethrotomy, which is the cause of a high percentage of recurrence, and holds the risk of compromising the success of further surgical procedures of urethroplasty. Differently, several techniques of urethroplasty offer a high percentage of success rate until 95%, as showed by our results.

Complicated urethroplasty: a guide for surgeons

Although straightforward male urethral stricture disease is commonly encountered in the scope of general urologic practice, complex urethral strictures are less common and require a more systematic approach. Complex urethral stricture surgery for long and panurethral strictures, after failed hypospadias repair, and for recurrent posterior urethral distraction defects requires a dynamic treatment paradigm. A multistaged urethral reconstruction is often necessary owing to hostile urethral tissue, especially after multiple previous procedures. A perineal urethrostomy sometimes offers improved quality of life for patients with complex urethral stricture disease, particularly if they have undergone previous failed repairs. Recurrent posterior urethral distraction defects are best treated with excision of the scarred urethral segment and re-anastomosis. Urethral stricture disease after treatment for prostate cancer requires multiple treatment approaches given the often poor tissue quality and likelihood of stricture recurrence.