Reconstruction of the penile urethra is a challenging exercise, and for many surgeons an ungratifying experience. The past three decades have seen us move from predominantly 2-staged surgery, through foreskin grafts, and then single stage flap reconstructions, and now in the 3rd millennium, for some situations 2-stage repair has again become the favoured option. Satisfying short-term solutions have sometimes resulted in poor long-term outcomes when reviewed 10 years later. Clearly there are still problems to be resolved, hence the need for continuing evolution in our surgical management. Lessons have been learned from the treatment of Lichen Sclerosus, from strictures following hypospadias repair, and strictures associated with severe spongiofibrosis. Management of these problems has traditionally been associated with not only a high incidence of restricture and fistula formation, but also with poor cosmetic results, something that men today find increasingly difficult to accept. Several considerations are fundamental to achieving the best functional and aesthetic results. These include the presence or absence of Lichen Sclerosus, the extent of urethral disease and its grade (i.e. mucosal disease or with accompanying spongiofibrosis); furthermore the use of non-genital grafts for urethral reconstruction when the local penile tissues are deficient or unhealthy. In arriving at our present strategy, a collaborative approach that integrates established urological practice with the different perspectives of a plastic surgeon (A.B.) has proved constructive and beneficial.
La reconstrucci6n de la uretra peneana es un reto, y para muchos cirujanos una experiencia ingrata. Se consideran los principios del tratamiento quirurgico y se realiza una revisi6n de las técnicas quirurgicas predominantes durante las ultimas tres décadas.
MÉTODOS/RESULTADOS: Las pasadas tres décadas nos han visto movernos desde el predominio de la cirugfa en dos pasos, pasando por los injertos de prepucio, y después las reconstrucciones con colgajo en un unico paso, yactualmente, en el tercer milenio,la reparaci6n en dos pasos ha vuelto a convertirse en la opci6n prejerida para algunas situaciones. Soluciones satisjactorias a corto plazo han tenido algunas veces malos resultados a largo plazo cuando se revisaron a los diez afios. Claramente todavza hay problemas por resolver, y por lo tanto la necesidad de seguir evolueionando en el tratamiento quirurgico. El tratamiento del liquen escleroso. de las estenosis post-tratamiento del hipospadias. y de Las estenosis asoeiadas con espongiofibrosis grave nos ha ensefiado algunas leceiones. El tratamiento de estos problemas se ha asociado tradicionalmente no s6lo con una alta incideneia de reestenosis y formaei6n de fistulas. sino también con resultados cosméticos malos. algo que hoy en dza los hombres encuentran. de una forma creeiente, dificil de aceptar. Para conseguir los mejores resultados funeionales y estéticos son fundamentales varias consideraeiones. Éstas incluyen la presencia o auseneia de liquen escleroso, la extensi6n de la enfermedad uretral y su grado (por ejemplo enfermedad de la mucosa o con espongiofibrosis acompafiante); ademas. la utilizaci6n de injertos no genitales para la reconstrucei6n de la uretra cuando los tejidos locales peneanos son defieientes o estdn enfermos.
CONCLUSIONES: Considerando la estrategia actual. un abordaje cooperativo que integre la practica urol6gica estableeida con la perspectiva diferente de eirujano plastico (A.B.) ha demostrado ser constructivo y benefieioso.
As we enter the third millennium, established beliefs about anterior urethral stricture disease are being challenged, both with regard to the aetiology, and also the surgical techniques that are used for anterior urethroplasty.
In adult patients, peniIe urethral strictures may be a feature of failed hypospadias, or of ischaemic scarring, or of inflammatory disease extending into the corpus spongiosum. In the previous century the predorninant aetiology of inflammatory strictures was infection with Neisseria gonorrhoea. BIenorrhagia or sexuaIIy transmitted diseases (STDs) are now an infrequent cause of urethral strictures in developed countries, though they are still a major problem in other less developed parts of the worId (1).
Today, the principal cause of devastating, chronic inflammatory strictures of the male urethra is a more recentIy recognised disease. Lichen Sclerosus (L.S.). Penile L.S. is also known by the nameBalanitis Xerotica Obliterans (BXO) (2, 3).
The surgical treatrnent of adult anterior urethral strictures has been a constantly evolving processo Significant recent changes include the wider use of buccal mucosa grafts in preference to both genital and non-genital skin grafts, and the use of dorsal inlay urethroplasties such as the Barbagli procedure (4,5). Moreover, in the penile urethra, incision of the urethral plate, as suggested by Snodgrass for childhood hypospadias surgery (6), is combined with dorsal placement of a grafi as suggested by Hayes (7), and Asopa (8).
AETIOLOGY OF PENILE URETHRAL STRICTURES
In adults, peniIe urethral strictures are commonly associated with faiIed hypospadias repairs, ischaernic scarring or Lichen Sclerosus (L.S.). Strictures resulting from hypospadias repair may be of a localised junctional nature involving the extemal urinarymeatus orproximal anastamosis, ormay involve the entire neo-urethra. They are frequentIy associated with other problems such as diverticulae, stones. hair, fistulae, cosmetic defects, or residual penile curvature. In these patients the foreskin is usuaIIy absent, and the vascularity of the residuaI penile skin is unpredictable. The dartos fascia may be inadequate to provide reliable vascular and mechanical support for a peniIe grafi or flap.
Ischaernic strictures are observed foI1owing urologicaI endoscopic procedures, after cardiovascular surgery (9, lO, Il) or after major trauma requiring prolonged catheterisation. In these patients, apart from the urethra and corpus spongiosum, the penis is usuaIIy otherwise normaI. The foreskin is frequentIy present and the vascularity of the penile skin anQ fasciaI layers is not comprornised, thereby aIlowingdeploymentofthe dartos fascia to provide vascular or mechanical support for grafis or flaps.
Strictures resulting from L.S. may be confined to the extemal urinary meatus and the fossa navicularis. or may affect the entire pendulous urethra (2, 3). In advanced disease the bulbar urethra may also become>
AETIOLOGY OF PENILE URETHRAL STRICTURES
In adults, peniIe urethral strictures are commonly associated with faiIed hypospadias repairs, ischaernic scarring or Lichen Sclerosus (L.S.). Strictures resulting from hypospadias repair may be of a localised junctional nature involving the extemal urinarymeatus orproximal anastamosis, ormay involve the entire neo-urethra. They are frequentIy associated with other problems such as diverticulae, stones. hair, fistulae, cosmetic defects, or residual penile curvature. In these patients the foreskin is usuaIIy absent, and the vascularity of the residuaI penile skin is unpredictable.
The dartos fascia may be inadequate to provide reliable vascular and mechanical support for a peniIe grafi or flap. Ischaernic strictures are observed foI1owing urologicaI endoscopic procedures, after cardiovascular surgery (9, lO, Il) or after major trauma requiring prolonged catheterisation. In these patients, apart from the urethra and corpus spongiosum, the penis is usuaIIy otherwise normaI.
The foreskin is frequentIy present and the vascularity of the penile skin anQ fasciaI layers is not comprornised, thereby aIlowingdeploymentofthe dartos fascia to provide vascular or mechanical support for grafis or flaps. Strictures resulting from L.S. may be confined to the extemal urinary meatus and the fossa navicularis. or may affect the entire pendulous urethra (2, 3). In advanced disease the bulbar urethra may also become involved leading to pan-urethral strictures (2, 3, 12). In the pres~nce ofL.S. there is usually, though not always, external evidence of the disease, with involvement of the glans, the foreskin, and sometimes the penile skin (2, 12). In addition to urethrop1asty, these patients may require other procedures such as circumcision or resurfacing of the glans (12) to improve both the sexual function and the aesthetic appearance of the penis.
SELECTION CRITERIA AND SURGICAL TECHNIQUES FOR PENILE URETHROPLASTY
Patients requiring penile urethroplasty may have either an essentially norma1 penis (ischaemic urethra1 strictures) or an abnormal penis (failed hypospadias or L.S.).
In the former group the urethra1 p1ate, the foreskin, the penile skin, and the dartos fascia are available for urethral reconstruction and so aone-stage augmentation urethrop1asty using a graft or flap may be appropriate. In the latter group with an abnormal penis, the urethral plate, the foreskin, the penile skin and the dartos fascia may be unavailable for urethral reconstruction. In such patients a staged substitution urethroplasty may be preferable (2, 5, 12, 13, 14, 15)
One-stage augmentation urethroplasty using a dorsal releasing incision and inlay patch graft.
Asub-coronal incision is made with degloving ofthe penis. The penile urethra is exposed, and the strictured segment is opened by a ventral midline incision (fig. lA). The urethral plate is incised longitudinally (fig. lE) in the dorsa1 midIine down to the corpora, and the wings of the urethral plate are mobiIised laterally (fig. lE-C). The graft (penile skin or buccal mucosa) is quilted into the resulting dorsal defect with interrupted absorbable sutures, and an augmentation ofthe urethral plate is achieved (fig. ID).
The urethra is tubularised by ventral closure of the two halves of the urethral pIate (fig. 1EF).Adartos fasciaI flap is fashioned to coverthe urethraI suture line, and the gIans and the penile skin are closed. AFoley 12 Ch. silicone catheter is Ieft in pIace (fig. IF) for 2 weeks. Suprapubic urinary drainage is unnecessary. Thiskind ofurethropIasty is feasibIe when the urethral pIate can be mobilized using a midIine incision, typically in patients with ischaemic strictures. The technique is not possibIe when the urethraI plate is densely scarred, hairy, or involved with L.S.
This procedure represents an evoIution ofour originaI dorsaI peniIe urethrop1asty technique described in 1996 (16) and it was suggested to us by our plastic surgery colleague (A.B). Hayes in 1999 (7), and Asopain 2001 (8) described similar techniques.
One-stage augmentation urethroplasty using a fascio-cutaneous island flap.
A midline 10ngitudinaI incision is outIined on the ventra1 penile skin (fig. 2A). The glans and the navicuIar fossa are opened, and the penile urethra is dissected from the tunica albuginea, to better expose the dorsal urethraI surface (fig. 2B). The abnormal segment of peniIe urethra is fully opened (fig. 2C), and aIongitudinaI ventraI penile skin island is eIevated on the dartos penile fascia (fig. 2D). The Ieft margin of the skin island is sutured to the Ieft margin of the opened penile urethra (fig. 2E), and the skin flap is rotated to coverthe urethral pIate, and sutured to the right peniIe urethral margin (fig. 2F). ThepeniIe urethrais rotated back to its originaI position (fig. 2G), the glans and the peni1e skin are closed over the flap (fig. 2H). AFoIey 12 Ch. silicone catheter is left in pIace (fig. 2H) for up to 2 weeks.
This kind of urethroplasty is advisabIe for patients with ischaemic penile strictures wherein the urethraI pIate is fibrous and requires augmentation with vascuIarised tissue. The technique is not feasibIe if the penile stricture is due to L.S., because 1eaving diseased urethra in situ or using any form of skin urethropIasty will inevitabIy Iead to recurrence (12). The surgicaI technique of using a 10ngitudinaI ventral peniIe skin isIand represents an evolution of the Orandi (17), and Quartey (18) procedures, as advocated by Jordan (19).
Two-stage substitution urethroplasty using a buccal mucosa graft.
At the first stage the urethral p1ate is excised and the glans is fully opened (fig 3A), and abuccaI mucosa graft is quiIted onto the glans sponge and tunica albuginea (fig. 3B).Further fixation of the graft to the wound bed is achieved by suturing a boIus tie-over dressing over the graft and Ieaving this in pIace for about lO days. 4- 6 months after the frrst stage, the patient is ready for urethral closure (fig. 3C). A2.5cm wide strip ofbuccal mucosa is incised (fig. 3D), excising the scar junction and any surplus width of mucosa (fig. 3E). The grafi is tubularised up to the meatus (fig. 3F). A dartos penile fasciaI flap is mobilised to cover the urethra (fig. 3G). The glans and the skin are closed (fig. 3H). AFoley 12 Ch. silicone catheter is lefi in pIace for lO days.
Such a full circumference substitution urethroplasty is the appropriate choice for patients with LS, or when the urethral plate has to be removed because it is unserviceable for any kind of augmentation urethroplasty.
In penile urethroplasties the Foley silicone catheter is of narrow gauge to facilitate the drainage of urethral secretions. It should be anchored to the abdominal wall and not left free or fixed to the thigh as is all too often seen in generaI urological practice. Immobilising the catheter in an upward direction not only reduces postoperative discomfort but also reduces the risk ofthe catheter tearing through the ventral closure when the penis has erections. The catheter is left in pIace for 10-21 days, but may be removed earlier if evidence of frank infection is present. After early removal of the catheter voiding urethrography may be considered, as fistula or extravasation are potential complications. Infection may compromise the survival of grafts or flaps and lead to stricturerecurrence, therefore antibiotic prophylaxis is used whilst the urethral catheter is in pIace. When buccal mucosa is introduced into the urethra, the antibiotic regime should take account of the anaerobic bacteria that are usually present. We favour co-amoxiclav if there is no penicillin allergy. Post-operative erections can be unpleasant or damaging to the repair in young adults who have a high libido.
Cyproterone acetate 300mg/day for 10 days prior to surgery can be considered in such patients (26). Necrosis of penile skin may occur after flap implications, we can rationalise the choice of operation for surgical repair. Recent trends in urethroplasty have been greatly influenced by the increasing popularity of buccal mucosa, given its ready availability, elasticity and other functional attributes. Indeed, the availability ofbuccal mucosahas revolutionised the management of urethral Lichen Sclerosus. A surgical protocol is presented for the management of penile urethral strictures.
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