31.1 Introduction

Urethroplasty surgery for urethral strictures is the preferred option to restore durable urethral patency offering excellent success rates. However, failure rates can be as high as 50% [1] for the most challenging patient presentations. In particular, patients with panurethral strictures (most commonly related to lichen sclerosus) and patients with multiple previous failed urethroplasties, such as hypospadias cripples, are considerably difficult to manage. Tissue scarring and a decrease in vascularity -be it due to the sclerosing disease process or secondary to recurrent instrumentation- impede wound healing and reepithelialization making stricture recurrences and in case of hypospadias cripples also fistula formation common. In addition to urethral complications, these patients are found to experience a diminished quality of life related to voiding and sexual dysfunction as well as depression [2, 3].

Often viewed as a last resort prior to abandoning the urethral outlet, creation of a perineal urethrostomy (PU) is a highly successful option for men with complex urethral stricture disease , and in some conditions may even halt the progression of disease [4]. However, amongst urologists, there appears hesitation to perform this procedure. In surveys of practicing members of the American and Dutch Urological Associations completed in 2002 and 2008, respectively, less than 10% of urologists had performed a PU in the previous year [5, 6]. Yet in recent years as the field of reconstructive urology continues to advance it appears that perineal urethrostomies are increasingly considered. Fuchs et al. noted a nearly ten-fold increase in PU procedures from 2008 to 2017, with also a trend towards performing the procedure in younger patients likely reflecting improved awareness of the limitations of tissue transfer [7].

31.2 General Indications

In general , PU is a reversible procedure, and this is utilized during staged urethroplasty. A generation of a neomeatus in the perineum is essential during the first-stage. In this setting, despite the intention for a complete reconstruction six or more months later, many patients may ultimately find PU as an acceptable diversion and elect to forgo the second stage. In fact, in those undergoing staged urethroplasty, only 24–58% of men pursued second stage, leaving 42–76% with a functional perineal urethrostomy [4, 8, 9].

More commonly, however, definitive PU is performed and the general indication is in individuals with complex anterior urethral strictures. Compared to extensive urethral reconstruction, PU is a relatively minor surgical procedure associated with earlier return to normal activity and catheter removal, while avoiding the morbidity of graft harvest site morbidity and maintaining more typical anatomy for aesthetic reasons. As such, PU may be a more sensible procedure in the elderly or in those with severe medical comorbidities for whom a prolonged surgery may be associated with higher perioperative morbidity and mortality [4]. Other times, the surgeon may recommend a PU due to poor quality of urethral and penile tissue, exhaustion of graft materials, and understanding of the disease process, which can contribute to inadequate reconstruction [4, 9]. Aptly put by Peterson et al., “heroic measures may not be justified” [4]. Finally, patients who would otherwise be candidates for a single-stage repair may elect to undergo PU instead of complex urethroplasty due to a history of multiple prior failed procedures and treatment fatigue. Barbagli et al. reported that patients electing PU instead of a complex urethroplasty were a mean age of 53 years, had undergone on average 4.5 procedures for hypospadias repair or 4.1 failed urethroplasty for other urethral conditions, and were unwilling to accept the possibility of another failed urethroplasty [9].

Outside of urethral stricture disease, a PU may be indicated in patients with traumatic or penile amputation. Following penile trauma or in the setting of penile or urethral malignancy, PU may be utilized as an alternative to placement of a suprapubic catheter or avoid more extensive surgery to create a urinary outlet such as appendicovesicostomy or even supravesical diversion such as an ileal conduit. The PU permits continent voiding and avoids complications associated with prolonged catheter use including urinary tract infection, bladder calculi, catheter blockage, and increased risk of squamous cell bladder carcinoma or risks of extensive surgery.

It should be noted that not all patients with urethral pathology should be considered for creation of PU. In patients with coexistent proximal urethral disease (posterior urethral stenosis or bladder neck contracture), a PU would obviously not relieve obstructive symptoms. In patients with urinary incontinence, creation of a PU could worsen urine leakage by bypassing the stricture, which in many cases comprises the patient’s continence mechanism. In this setting, continuous leakage of urine through a PU is likely to cause wound complications. Additionally, the presence of a PU would make subsequent placement of an artificial urinary sphincter more challenging technically as well as likely increase the risk of complications [10].

31.3 Perineal Urethrostomy Techniques

There are several techniques described to generate a PU and approaches can broadly be divided into two categories: those associated with transection of the urethra and non-transecting techniques.

Non-transecting techniques such as the Johanson and Blandy techniques preserve the urethral plate, and thereby retrograde blood supply from the dorsal penile artery. This may decrease the rate of postoperative complications, specifically stenosis of the neomeatus [11]. Additionally, by maintaining the urethral plate, these techniques allow for the possibility for the urethra to be re-tubularized at a later date. In contrast, advantages of transecting techniques, such as the 7-flap, lotus petal flap, and also augmented PU techniques, are a more complete mobilization of the proximal urethral stump. This facilitates a tension-free anastomosis, especially in patients with increased skin-to-urethra length (e.g., obese patients or patients with very proximal urethral strictures). However, while generally also reversible, the urethral transection and ligation of the distal urethra makes a subsequent reversal a more complex endeavor.

31.3.1 Non-transecting Techniques

31.3.1.1 Johanson Technique

Originally described in 1953 as the first-stage of a staged urethroplasty for pendulous urethral strictures, the Johanson technique has been adapted for use in the bulbar urethra for staged procedures as well as for permanent diversion in the form of PU [12]. In principle, the Johanson technique for PU creation involves marsupialization of the urethra to adjacent perineal skin and serves as blue-print of generating a PU as its evolution by the more elaborate techniques discussed below have some elements in common with the Johanson technique.

The patient is placed in a high lithotomy position. A vertical midline incision is made on the perineum extending from the posterior aspect of the scrotum to approximately 1–2 cm anterior to the anus (Fig. 31.1). After exposing the bulbar urethra, a ventral longitudinal urethrotomy is performed and extended proximally until healthy urethra is encountered. An incision of several centimeters is recommended to avoid stenosis of the neomeatus (Fig. 31.2). The presence of proximal urethral strictures, stenoses or bladder neck contractures should be excluded either with calibration to 24-28F or cystoscopically. As significant bleeding of the incised corpus spongiosum can be encountered, the cut edge of the corpus spongiosum can be oversewn with running locked absorbable sutures. The edges of the urethrotomy are then matured to the perineal incision skin edges with interrupted absorbable sutures [1, 8, 13].

In the event that the urethrostomy cannot be matured to the perineal skin in a tension-free fashion, scrotal skin can be invaginated towards the urethrotomy, with a vertical incision made along the median raphe of the scrotum to be used for stoma maturation [1, 8]. A urethral catheter is placed through the neomeatus but can typically be removed within 1 week .

The Johanson technique is a familiar concept to most reconstructive urologists due to its use as a first-stage approach for staged urethroplasty. However, due to the limited elasticity of the perineal skin, there may be significant tension when maturing the urethrostomy, particularly at the posterior-most aspect. This may predispose the incision to wound dehiscence and subsequent stenosis of the neomeatus. To address this concern, an invaginated scrotal flap as described above should be considered albeit this can be inconvenient for voiding. Alternatively, McKibben describe the utilization of a Z-plasty technique on the inferior aspect of the perineal incision to construct a tension-free urethrostomy with excellent success [14]. Regardless, use of this approach may be best reserved for thin individuals with pliant perineal skin in whom a tension-less anastomosis is more feasible.

31.3.1.2 Blandy Technique [15, 16]

Developed as a modification of the Johanson technique due to high stenosis rate at the proximal apex of the PU, this technique was first described in 1968 [15]. By developing an inverted U-shaped scrotal flap, this approach can be used as a first-stage of a staged urethroplasty or for definitive PU.

The patient is placed in high lithotomy position and urethroscopy may be performed at the start to identify the proximal end of the stricture. This is marked on the skin and marks the point at which the flap would need to reach. The apex of the flap is marked out to be 3 cm anterior to this to allow the flap to drop into the urethra without tension (Fig. 31.3). The flap is marked out with the distal end of the flap being about 3 cm in width and a corresponding base created with an approximately 3:1 ratio. A 4 cm vertical midline incision is marked out anterior to the apex of the flap to form the edges of the dorsal urethral plate. Incision is made in the pre-marked lines and the flap is developed with a full thickness fat pad directly off of the underlying bulbocavernosus muscle in order to ensure good vascular supply to the apex of the flap. Next, the bulbar urethra is exposed, a ventral longitudinal urethrotomy is performed and extended proximally while placing stay sutures through mucosa and corpus spongiosum (Fig. 31.4) until healthy urethra is encountered and proximal urethral obstruction excluded. The urethrotomy should measure several centimeters (about 4–6 cm) to ensure durability of an adequately sized opening. The edge of the corpus spongiosum and the edge of the urethral mucosa are closed laterally with 4–0 absorbable sutures (Fig. 31.5). To mature the urethrostomy, three apical sutures are pre-placed in the proximal urethral opening and corresponding area on the flap (Fig. 31.6) allowing for optimal visual exposure, which is obscured once the inverted U-shaped flap is advanced into the defect. Next, the sutures are tied leading to a parachuting of the perineal skin flap to the proximal urethral stump (Fig. 31.7). The remaining skin incisions which were not utilized in maturing the PU are then re-approximated with absorbable suture (Fig. 31.8). A 20 Fr urethral catheter is placed and removed after 7–10 days.

The main drawback of the Blandy technique is that it relies on an accurate pre-incision assessment of the length of the flap needed to construct a tension-free anastomosis. Unfortunately, the preoperative assessment of urethral stricture disease is imperfect, with one study noting a correlation coefficient of only 0.69 between preoperative RUG and intraoperative stricture measurement [17]. It follows that if the stricture extends more proximally than expected before the initial incision, the flap may not be long enough to ensure a tension-free anastomosis and predispose to PU failure. Also, in its original report, about 10% of patients required a revision due to necrotic tip of the flap and some patients needed to self-dilate to break down skin bridges between suture lines. [16]

31.3.2 Transecting Techniques

31.3.2.1 7-Flap Technique

The 7-flap technique was first described in 2011 by French et al. [18] This approach utilizes a lateral-based perineal skin flap to create the urethrostomy. It also employs a vertical midline perineal incision, affording flexibility if a one-stage urethral reconstruction is intended but not possible and instead a PU is necessary. Conversely, if a PU is being pursued but an orthotopic reconstruction is instead deemed possible this can be performed through this incision.

The patient is positioned in lithotomy position and the 7-flap delineated (Fig. 31.9) and the skin incised through a vertical midline perineal incision which is the stem of the “7”. The bulbar urethra is exposed and transected at the distal-most possible level as determined by cystoscopy. The distal urethral stump is oversewn with running absorbable suture. The proximal urethral segment is spatulated at the at 9 o’clock aspect for about 1 cm and proximal urethral patency ensured by calibration or cystoscopically. On the same side as the urethral spatulation, the 7-shaped skin flap is created and tailored to fit the distance to the proximal apex of the spatulation (Fig. 31.10). The incision can be extended if a longer flap is needed to achieve a tension-free anastomosis. When developing the flap, it is necessary to ensure adequate thickness of the flap to prevent flap necrosis as well as an appropriate ratio of base to length of the flap (3:1 or more).

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