• Our aim is to provide free detailed comprehensive manual for urologic surgical procedures. This site should serve as a valuable reference for urologic residents and medical students in training.

  • Urethroplasty

    ABOUT THE AUTHOR

     

     

     

     

     

     

     

     

     

    Dr. Jill Buckley is a graduate of the David Geffen School of Medicine at UCLA and completed a 6-year urology residency at the University of California, San Francisco. Following residency she obtained the coveted Trauma and Reconstructive Surgery Fellowship under the guidance of Dr. Jack McAninch. She spent the first part of her career at the Lahey Clinic in Massachusetts before joining UC San Diego Health Systems as an Associate Professor in the Department of Urology. She has published numerous manuscripts and book chapters in her respective field and has accepted several national and international speaking engagements.

    She joined the UC San Diego Health System to develop and provide expertise in Genital-Urinary Reconstruction. Her focus is to rehabilitate the lower urinary tract from events related to severe pelvic/perineal trauma, complications from pelvic and prostate cancer therapy, radiation therapy complications and de novo as well as redo urethral stricture disease. She has had vast experience with urethral reconstruction, urinary fistula repair, bladder neck contractures, post prostatectomy male incontinence and complex redo pelvic and urethral surgery.

    Jill C. Buckley MD, FACS

    200 West Arbor Drive MC 8897

    San Diego, CA 92103

    INTRODUCTION

    Anastomotic Urethroplasty

    Procedure:

    Indications: Short Bulbar Urethral Strictures (<2.5cm) with spongiofibrosis

    Contraindication: Fossa Navicularis, Distal Urethral or Penulous Stricture, Stricture >2.5cm,

    1. Positioning: High Lithotomy: (Social lithotomy if sitting) This provides optimal access for all perineal surgery. Care must be taken when positioning the patient for perineal surgery especially ensuring the hip, knee and ankle are in alignment. There should be no pressure or weight on the calf or lateral aspect of the trochanter, tibula or ankle.
    2. Special Equipment: Yellowfins, Perineal Bookwalter (disposable Lone Star Retractor can also be used), thin sharp blue hooks

    SURGICAL TECHNIQUE

    Incision: Perineal, Midline, Vertical

    • - Use a 15 blade knife to make vertical perineal incision
    • - Divide subcuticular tissue
    • - Identify and divide bulbospongiosum muscle sharply
    • - Retract muscle and continue dissecting spongiosum.
    • - After completely encircling the spongiosum pass a vessel loop to provide additional retraction
    • - Continue to mobilize the urethra proximally and distally
    • - Pass a 20 fr red rubber catheter to identify the area of stricture
    • - Completely transect the urethra (horizontally) at the tip of where the red rubber catheter stops
    • - Place stay sutures on the proximal and distal ends of the urethra
    • - Resect additional scar tissue until you are into health mucosa
    • - Pass a 26fr bougie proximally and 24fr distally (should be no resistance)
    • - Spatulate tissue on the dorsal side distally, and the ventral side proximally for 1cm
    • - Ensure with the penis on full stretch a tension free anastomosis can be achieved
    • - Anastomos the dorsal wall in a single interrupted layer using 5.0 absorbable suture (full thickness)
    • - Anastomos the ventral wall in two layers: inner layer interrupted 6.0 absorbable suture mucosa to mucosa, outer layer interrupted 5.0 absorbable suture adventia of the spongiosum for hemostatis
    • - Place 16fr silastic foley catheter prior to completing the second layer of the ventral wall anastomosis
    • - Reapproximate the bulbospongiosum muscle with interrupted 4.0 absorbable suture
    • - Place ¼ inch penrose drain underneath the muscle and brought out a separate incision in the lateral perineal area. Suture into place.
    • - Close the subcutaneous tissue in two layers with 4.0 absorbable suture
    • - Close the skin incision with interrupted 4.0 absorbable suture

    POTENTIAL COMPLICATIONS

    Excessive tension: Be sure the stricture is amenable to excision with primary anastomosis. When strictures are longer than 2.5cm it becomes difficult to ensure the anastomosis can be done in a tension free manner. Tension leads to failure.

    Inability to mobilize the urethra: Anastomotic urethroplasty is dependent on the ability to mobilize the urethra. The optimal and most successful location for this is the bulbar urethra. The pendulous and distal urethra are much less compliant and more difficult to mobilize and should only be considered for this repair in very short stricture (≤1 cm).

    Erectile Dysfuction: Erectile dysfunction has been reported in ~3.0% of patients. Our most recent review of our database found no statistical significant change as an overall group. The risk of a change in erections was especially low in patients under the age of 45yrs (< 1.0%). When a change in erections is noted, it typically occurs near the proximal bulbar urethra. Bipolar electrocautry is recommended to minimize electrocautry spread as well as minimal dissection around the membranous urethra where nerves travel.

    Penile Shortening/Curvature: Patients may complain of penile shortening or curvature when proper mobilization was not achieved. This typically results from surgeon inexperience and/or improperly assessment of the length of the stricture. Longer urethral strictures require onlay grafting.

    Recurrent Stricture: Can be due to an error in judgment and/or in error in technique. Tension on the anastomosis from inadequate mobilization, inadequate spatululation, or narrowing of the anastomosis at reconstruction will lead to failure as well as improper case selection. Both are usually a result of inexperience or an inability to perform the necessary operation. It is important to have a complete reconstructive armamentarium to perform the surgery required not planned.

    OUTCOMES

    Experienced male reconstructive surgeons at recognized centers of excellence, report success rates between 90%-98%. Our results mirror those with a 97% stricture free rate. The high complexity and low prevalence of urethral stricture disease warrant referral to a tertiary reconstructive center of excellence.

    REFERENCES

    1. Barbagli G, De Angelis M, Romano G, Lazzeri M. Long-term followup of bulbar end-to-end anastomosis: a retrospective analysis of 153 patients in a single center experience. J Urol. Dec 2007;178(6):2470-2473.
    2. Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol. Apr 2002;167(4):1715-1719.
    3. Eltahawy EA, Virasoro R, Schlossberg SM, McCammon KA, Jordan GH. Long-term followup for excision and primary anastomosis for anterior urethral strictures. J Urol. 2007 May;177(5):1803-6.
    4. Terlecki RP, Steele MC, Valadez C, Morey AF. Grafts are unnecessary for proximal bulbar reconstruction. J Urol. 2010 Dec;184(6):2395-9.

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