17. Surgical Reconstruction of Panurethral Stricture Disease

Pankaj M. Joshi¹, Faisal Alhajeri¹ and Sanjay B. Kulkarni¹

(1)

Kulkarni Reconstructive Urology Center, Pune, India

Pankaj M. Joshi

Keywords

Panurethral strictureOne stage urethroplastyLichen sclerosus

17.1 Introduction

Panurethral strictures involve the urethra from the meatus to the bulbomembranous junction . Lichen sclerosus and iatrogenic causes are two of the most common causes of panurethral strictures. Iatrogenic causes are on the rise, especially because patients are often subjected to dilatation and intermittent self-catheterization. The best option for management of a panurethral stricture is urethroplasty. We have published extensively on the management of panurethral stricture and the change from dilatations to flaps to grafts. The manuscripts are available in the Hinmans Atlas of Urology and UCNA [1–3]. In this chapter, we wish to highlight the decision-making process, surgical craft tips and the management of complex panurethral strictures.

17.2 Materials and Methods

At our tertiary referral center for the management of urethral strictures in Pune, we have received patients from all over India and the world, including patients with panurethral strictures. We have performed more than 4350 surgeries to date. A detailed history of the patient is taken, including any previous surgery. The clinical examination involves looking for lichen sclerosus. Occasionally, patients will have urinary retention and they are then referred with a suprapubic tube. Ultrasound is performed to look for renal health and rule out hydronephrosis. Uroflow forms an integral part of the workup as a baseline test. Usually patients come with a urethrogram. In our unit, we perform the urethrogram ourselves in the operating room (OR) under C-Arm on the day of urethroplasty. Patients are given povidone iodine gargles and Poviodine iodine or Chlorhexidine for local application to prepare for muccal mucosa grafting. Third generation cephalosporin IV antibiotic is started the evening prior to surgery. The surgical technique will depend on the type of panurethral stricture.

17.3 Surgery Techniques

17.3.1 Panurethral Strictures: Single Stage Versus Two Stage

The results of a randomized study by Dubey et al. [4] suggested the use of a single stage Buccal graft urethroplasty versus a staged approach. A multicenter study by Warner et al. [5] highlighted the use of a single stage approach over a staged approach and flaps in many high-volume centers across the globe. We tend to have a single stage approach as much as possible which has now been proven by the above two studies. This is important in lichen sclerosus which is a genital skin disease and where two staged urethroplasty is not recommended due to the risk of recurrence. (Fig. 17.1)

../images/468369_1_En_17_Chapter/468369_1_En_17_Fig1_HTML.png — Fig. 17.1

Lichen sclerosus causing Panurethral stricture

Our approach is to perform a small caliber endoscopy using a 4.5 Fr ureteroscope. Occasionally we have seen urethral stones and bladder stones which had to be addressed intraoperatively and would otherwise have been missed.

If the urethra accepts a 4.5 Fr ureteroscope or a 3 Fr guide wire, it can be managed with a single stage approach.

17.3.1.1 Positioning and Initial Steps

The patient is nasally intubated and two teams work simultaneously at the donor and the recipient site, with separate sets of instruments. The oral mucosa is harvested from both cheeks as described by Barbagli et al.(ref) The patient is placed in a simple lithotomy position , with heels carefully placed in Yellofin ® stirrups (Allen Medical Systems, Acton, MA; USA) with no pressure on the calves, to avoid peroneal nerve injury. The suprapubic, scrotal and perineal skin is shaved, disinfected using chlorhexidine, and draped. Methylene blue is injected into the urethra.

17.3.1.2 Incision

Methylene blue stains the strictured urethra. It helps in identifying the lumen (Fig. 17.2). A midline perineal incision is made and the bulbospongiosus muscle is exposed. In the lower half, the muscle wraps around the bulbar urethra. In the upper half, a sleeve of muscle extends to the corpora (Fig. 17.2). This is the bulbocavernosus part (Figs. 17.3 and 17.4). Only this part of the muscle is incised to gain access to the dorsal wall of the urethra. This is therefore a muscle preserving urethroplasty technique.

../images/468369_1_En_17_Chapter/468369_1_En_17_Fig2_HTML.png — Fig. 17.2

Injecting methylene blue in urethra

../images/468369_1_En_17_Chapter/468369_1_En_17_Fig3_HTML.png — Fig. 17.3

Incising bulbocavernosus muscle

../images/468369_1_En_17_Chapter/468369_1_En_17_Fig4_HTML.png — Fig. 17.4

One side dissection of bulbospongiosus muscle

17.3.1.3 Penile Invagination

The trick to invaginate the penis is to incise on the fascia above the urethra. Typically, a right-handed surgeon would use his left hand to push the penis down in the perineum and the dissection is performed on the left side of urethra (Fig. 17.5). By using the push technique and dissection, the penis can be invaginated. The step is simple and would not take more than 5 minutes even in novice hands provided the plane is correct. We were able to invaginate the penis even in redo cases where it could be challenging.

../images/468369_1_En_17_Chapter/468369_1_En_17_Fig5_HTML.png — Fig. 17.5

Penile Invagination

17.3.1.4 Urethral Dissection

The urethra is dissected from the underlying corpora similar to the dorsal onlay technique. Care needs to be taken that one does not enter the intercrural plane. The urethra is rotated on the long axis without mobilising circumferentially. The neurovascular supply from the right side is kept intact (Fig. 17.6).

../images/468369_1_En_17_Chapter/468369_1_En_17_Fig6_HTML.png — Fig. 17.6

One sided dissection of anterior urethra

17.3.1.5 Urethral Incision

A dorsal incision is made in the urethra across the full length (Fig. 17.7). Proximal one needs to be beyond the stricture and should see good pink supple urethral lumen. We use a broad Debakey forceps to retract the urethra intraluminally. The forceps should lie horizontal to the ground. This means the dissection has been completed. Proximal the urethra turns in to the perineum to become almost horizontal, therefore the forceps should lie horizontal. Any angle means that our dissection proximal may not be complete and this can be a cause of proximal failure. Distal dissection is done up to the fossa navicularis . The penis is brought back to the pubic region and a small Debakey forceps is inserted in the meatus. A wide dorsal meatotomy is performed externally (Fig. 17.8). This meatotomy should meet the dorsal incision in the urethral plate.