//Two-Sided Bulbar Urethroplasty Using Dorsal Plus Ventral Oral Graft: Urinary and Sexual Outcomes of a New Technique
Two-Sided Bulbar Urethroplasty Using Dorsal Plus Ventral Oral Graft: Urinary and Sexual Outcomes of a New Technique2017-04-05T18:51:42+00:00

Two-Sided Bulbar Urethroplasty Using Dorsal Plus Ventral Oral Graft: Urinary and Sexual Outcomes of a New Technique

 

pdf chirurgia uretrale

Authors:
Enzo Palminteri, Elisa Berdondini, et Al.

Publication:
THE JOURNAL OF UROLOGY, May 2011

Volume:
Vol. 185, 1766-1771

Center:
Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy

 

 

Abstract

Purpose: Repair of bulbar strictures using anastomotic techniques may cause sexual complications, whilst one-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a two-sided dorsal plus ventral graft (DVG) urethroplasty by preserving the narrow urethral plate in tight strictures.
Materials and Methods: Between 2002 and 2010, 105 men with bulbar strictures underwent DVG urethroplasty. Herewith results are reported on a homogeneous group of 73/105 cases in whom buccal mucosa (BM) was used as a graft and findings at >1 year follow-up.
The urethra was opened ventrally; the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter, the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need of any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire.
Results: Mean follow up was 48.9 months. Mean stricture length was 3.3 cm. Of these 73 cases, 64 (88%) were successful and 9 (12%) were failures with re-stricture. Furthermore 49/73 cases who preoperatively were sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life.
Conclusions: In tight bulbar stricture, the dorsal plus ventral BM graft provides an adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.

Introduction

Bulbar urethral strictures are treated by various reconstructive techniques techniques1-4. Generally, short strictures (< 2 cm) are treated with excision and anastomotic urethroplasty (AU), while longer strictures are repaired by patch urethroplasty preferably using a buccal mucosa (BM) graft1-4. In 1996, Barbagli et al.5 introduced the dorsal grafting procedure through a dorsal urethrotomy approach. Morey and McAninch6 reported results obtained with the ventral graft technique. In 2001, Asopa et al.7 described the dorsal graft urethroplasty using a ventral urethrotomy approach. Recently, the location of the patch has become a contentious issue with various series using the graft placed either ventrally or dorsally to augment the urethra4, 8, 9.
However, AUs showed a significant incidence of sexual complications and one-side graft procedures could be insufficient to provide a lumen of adequate width in strictures with a particularly narrow area2, 10 – 13.
Recently, we described a new technique for the repair of tight bulbar strictures, consisting in a combined dorsal plus ventral graft (DVG) urethroplasty, without transecting the urethra but augmenting the preserved narrow urethral plate in order to obtain an adequate urethral augmentation and to avoid sexual complications14.
Aims of the present report are to describe in detail: a. our technique following further experience; b. functional results obtained in a larger population and with a follow-up of more than 1 year; c. results also in terms of sexual outcome.

Material and Methods

From March 2002 to March 2010, 105 males with tight bulbar urethral strictures underwent DVG urethroplasty in our Center. In the present study, we analysed a homogeneous group of 73/105 cases, in whom the BM had been used as graft and follow-up > 1 year had been carried out. Seven patients were excluded because foreskin plus BM had been used as grafts; 8 were excluded because heterologous porcine small intestinal submucosa (SIS) was used as graft [15]; 17 were excluded because follow-up was < 1 year.
Mean age of patients was 39.2 + SD 14.48 years (range 8-78). Stricture etiology was unknown in 46 (63%) cases, catheter in 20 (27%), trauma in 3 (4%), instrumentation in 3 (4%), and infection in 1(1%). Stricture length was 1 to 2 cm in 13 (18%) patients, >2 to 3 cm in 33 (45%), >3 to 4 cm in 19 (26%), >4 to 5 cm in 4 (5%), >5 to 6 cm in 2 (3%), and >6 cm in 2 (3%). Mean stricture length was 3.3 cm (range 1 to 10).
A total of 51/73 patients (70%) had undergone previous treatments before referral to our Center : dilatation in 2 (3%), internal urethrotomy in 29 (40%), multiple treatments in 20 (27%). In cases previously submitted to urethrotomy, the number of urethrotomies ranged from 1 to 9 (mean 4).
Preoperative evaluation included: clinical history, physical examination, urine culture, uroflowmetry, retrograde-voiding cystourethrography and urethroscopy.

Surgical Technique

With the patient in the lithotomy position, a Y-inverted perineal incision is made and the bulbocavernous muscles are divided, exposing the bulbar urethra. Using a ventral-sagittal urethrotomy the strictured urethra is opened with the aid of a guide wire and methylene blue previously injected to define the narrow lumen: this step avoids losing the lumen and does not damage the urethral plate during the urethral opening. The urethra is left open for 1 cm both proximally and distally in the healthy urethra.

Dorsal Graft: as suggested by Asopa, the exposed dorsal urethra was incised in the midline down to the tunica; the margins of the incised dorsal urethra were dissected from the tunica albuginea without lifting the two halves of the bisected urethra: an elliptical raw area was created where the first graft was placed as a dorsal inlay, quilted to the corpora cavernosa and sutured to the urethral margins7 (Fig. 1A).
Ventral Graft: following dorsal augmentation, the urethra was also graft-enlarged ventrally according to the McAninch group procedure6, 12. The second graft was sutured laterally to the left mucosal margin of the urethral plate with a running suture 6-zero. The catheter was inserted; the graft was rotated and sutured laterally to the right mucosal margin (Fig. 1B).
Thus a neourethra was created by anastomosis of the BM grafts in an inlay/onlay patch fashion to the mucosal margins of the bisected urethral plate. Finally, the spongiosum was closed over the ventral graft with 4-zero running suture (Fig. 2).
The double patch was used to better enlarge the urethra in tight strictures characterized by a narrow residual urethral plate, scarred and/or compromised by stenotic rings, in which a single patch appeared inadequate to make a sufficiently wide lumen. Preoperative urethrogram gives information regarding the degree of urethral narrowing (Fig. 3); however the intraoperative urethral conditions determine the choice of surgical technique.
A 2-team approach was used, with one team harvesting the BM while the 2nd team exposed the stricture. The BM was harvested from the cheek. In 68 patients, a single graft was harvested from only one cheek (right in 67 patients and left in 1) and thereafter tailored into two smaller grafts according to the length of the dorsal and ventral openings of the urethra, while in 5 patients the two BM grafts were harvested bilaterally from both cheeks.
Mean length of the harvested BM graft was 6 cm (range 4.5 – 8) and mean width was 1.8 cm (range 1 – 2.5). Overall, mean length of the dorsal graft augmentation was 2.3 cm (range 1 – 10) and mean length of the ventral graft augmentation was 4.4 cm (range 2 to 11). In one case, two dorsal BM grafts were placed serially (total length 10 cm) plus one ventral BM graft; in another case, one dorsal BM graft was used plus two ventral BM grafts (total length 11 cm) placed serially.
A 16-18 Fr silicone Foley catheter was left in situ. Patients were discharged after 3 days. Voiding cysto-urethrography was performed upon catheter removal, 3 weeks after surgery.

Post-operative assessment

Follow- up assessment included uroflowmetry and urine culture every 4 months in the first year and annually thereafter. Urethrography and urethroscopy were performed in patients presenting obstructive symptoms or peak flow rate (Qmax) < 14 mL/s. Clinical outcome was considered a failure when any postoperative procedure was need, including dilatation.
The prevalence of postoperative sexual disorders was investigated using the validated questionnaire (see Appendix), previously adopted by Morey and Kizer10, and Coursey et al.16 in their series of urethroplasties. The questionnaire was delivered by mail one year after surgery to 49 sexually active patients selected according to: age range 18 – 60 years old, no diabetes or vascular disease present and no further treatment required following our urethroplasty. This questionnaire was used since one of the aims of the present investigation was to assess the subjective postoperative changes and to compare our data with findings reported by other Authors using the same questionnaire10.

Results

Mean follow-up was 48.9 months (range 12-93). Of the 73 cases, 64 (88%) were successful and 9 (12%) were failures.
There were no early postoperative complications, such as wound infections, hematomas, bleeding. In 4 cases, at the voiding urethrography following catheter removal at 3 weeks, a mild leakage at the graft anastomosis was observed, that, however, resolved spontaneously with a 12 Fr catheter for two additional weeks.
In the 64 successful cases, mean postoperative Qmax was 30.2 mL/s (versus the mean preoperative Qmax 7.5 mL/s), mean stricture length was 3.3 cm (range 1 – 8), mean dorsal graft length 2.2 cm and mean ventral graft length 4.4 cm.
In the 9 cases of failure, mean stricture length was 3.9 cm (range 2 – 10), mean dorsal graft length 3.3 cm and mean ventral graft length 4.4 cm. Of the 9 failures, 6 patients developed re-strictures < 1.5 cm long and were submitted to internal urethrotomy. Three patients developed restricture > 3 cm: the fibrotic urethral tract was opened leaving a perineal urethrostomy and the patients are currently awaiting a staged solution. Recurrences developed within 1 year after surgery in 3 cases, within 2 years in 3 and within 3 years in 3.
None of the 49 sexually active men, reported postoperative penile curvature or shortening, impaired erection or dissatisfaction regarding erection and sexual activity compared to the pre-operative status. Moreover, erectile improvement was reported by 7 patients (14%) and by 3 partners (6%), increased frequency of intercourse was reported by 2 (4%), ejaculatory improvement was reported by 6 (12%). Only 2 patients (4%) reported decreased ejaculatory flow and one (2%) slightly decreased glans sensitivity. All 49 (100%) patients reported overall satisfaction following urethroplasty. When compared to data reported by other Authors, using the same erectile function questionnaire following AU, our data showed better results (Table 1)10.

Discussion

Graft techniques

Long bulbar strictures are usually treated by dorsal or ventral oral graft urethroplasty4, 8, 9, 12. Dorsal grafting is performed using Barbagli’s approach or Asopa’s approach. A disadvantage of the former is a more extensive dissection-mobilisation of the urethra; this approach might impair erection and the bulbar arteries when dissection from the corpora is very proximal 9, 17. Asopa’s procedure is easier to perform as the urethra is not dorsally mobilized; nevertheless, the augmentation is not as wide as that achieved using Barbagli’s approach7. With regard to the ventral grafting, McAninch’s group stated that the graft may be inadequate to augment a very narrow urethral plate and, in these cases, suggested a wider graft12.
Barbagli stated that his technique offers a wider augmentation than ventral or dorsal grafting using the ventral-urethrotomy approach. He suggests that the technique (ventral or dorsal graft) should be selected according to the width of the urethral plate13. In reality, the urethral plate can be assessed only after urethral opening because the urethrogram often underestimates the severity of the stricture18. Ventral urethrotomy provides easy access to the urethra that with good visualisation of the urethral plate allows to establish whether a dorsal or a ventral graft would be more appropriate. Furthermore, in tight strictures, with a very narrow urethral plate, in which a single patch is insufficient for reconstruction of an adequate lumen, the ventral access allows to perform double dorsal-ventral grafting14, 15.

Rationale of DVG technique

In 2008, we described the DVG for tight bulbar strictures, postulating some advantages14. The fibrotic tissue is partially excised while preserving the remaining urethral plate. Avoiding a wide single ventral graft, the double grafting may reduce the possibility of fistula and diverticula. The dorsal augmentation could be small due to reduced mobilization of the urethral plate that the ventral approach allows; thus, the additional second graft could correct the initial use of a single dorsal graft that was intraoperatively considered to be insufficient for adequate augmentation.
In non-obliterative short strictures, the DVG represents an alternative to the aggressive anastomotic urethroplasty (AU) since, avoiding transection of the spongiosum, it preserves the urethral plate14, 18. The aim of DVG was to maintain the integrity of the urethral vascularity and the urethral length, thus reducing the sexual complications related to the AUs10, 11, 16, 19 – 21.

Anastomotic techniques

Short bulbar strictures (< 2 cm) are traditionally treated by excision and primary anastomosis (EPA); recently an extended anastomosis urethroplasty (EAU) has been described for stenoses even up to 5 cm10. However, in addition to the excision, the spatulation of the stumps lengthens the gap increasing the risk of complications19, 22. Following the urethral transection, the stricture is often longer than described at urethrography and this discrepancy causes problems when performing the AU. Unlike the transverse section, the ventral urethrotomy offers the possibility of choosing an appropriate solution after evaluation of the stricture and its length.
AUs showed a more important impact on sexual life than that of graft techniques2, 10, 11, 16, 20, 23. Focusing on bulbar repair, the literature showed a significant rate of sexual complications following AUs (Table 2). Barbagli et al. reported cold glans (11.6%) and glans not full during erection (18.3%)11; these complications may be related to vascular injury in the spongiosum distally to the transection. Al-Qudah and Santucci, directly comparing AUs versus BM graft techniques, in bulbar repairs, showed a higher incidence of sexual complications following AUs: they are the first to highlight the issue graft versus anastomotic urethroplasty for short bulbar strictures21, 24.

Urinary and sexual results of DVG technique

In our series, population characteristics (age, stricture length and etiology), criteria of urinary outcomes and follow-up are comparable to those used in other studies4, 8, 9, 16, 23. A successful urinary outcome of 88% was achieved, but we realize that a stronger follow-up methodology could detect unrecognized re-strictures4. With regards to our short re-strictures treated by urethrotomy which are successful at the moment, we emphasize that many recurrences after BM urethroplasty are diaphragms or rings occurring at the anastomotic site between the graft and urethra. This explains why these rings could be successfully dispelled by a simple urethrotomy. These should be considered differently from true longer recurrences associated with a wider spongiofibrosis4.
Our sexual results were compared to those previously reported using the same sexual questionnaire after AUs (Table 1)10; even if differences in results between the two series could be in part due to differences in population characteristics, we highlight that, in our experience, no preoperative sexually active men reported erectile impairment postoperatively or overall dissatisfaction regarding sexual life. A positive impact on erectile function was noted postoperatively in 14% of cases (versus complete loss of erection in 18% of cases with EPA); an increased frequency of intercourse was reported in 4% (versus a decreased frequency in 22% and 16% of cases, with EPA and EAU, respectively)10.
Sexual complications after AUs have an impact on the quality of life, which may be a more important issue than the risk of restricture. Successful outcomes, in urethral repair, should be assessed not only by objective voiding parameters but also by subjective parameters influencing patient satisfaction and these latter must be considered in the choice of treatment. Larger series and adapted validated questionnaires are necessary to establish whether DVG techniques represent an alternative to traditional anastomotic techniques which are now supported by the current evidence as the method of choice.

Conclusions

The optimal technique for bulbar urethral stricture repair should guarantee optimal urinary and sexual outcomes. DVG urethroplasty is a valid technique that offers the possibility of performing a wide urethral enlargement also in severe strictures by preserving the urethral plate and length. This technique guarantees good urinary outcomes preserving, at the same time, sexual function.
Later graft failure may contribute to deterioration of the final outcome; therefore, direct comparison of the different techniques are necessary to clarify the various results.

 

Abbreviations and Acronyms.
DVG = Dorsal plus Ventral Graft
AU = Anastomotic Urethroplasty
EPA = Excision and Primary Anastomosis
EAU = Extended Anastomotic Urethroplasty

 

Table 1.
Postoperative sexual function results based on sexual function questionnaire (see appendix): comparison between results following our DVG and results reported, using the same questionnaire, as Morey following AUs 10.

DVG*
%
EPA**
%
EAU***
%
Erection improvement 14 - -
Erection worsening 0 - -
Complete loss of erections 0 18 0
Chordee 0 44 0
Decreased penile length 0 22 33
Increased penile length 2 - -
Decreased intercourse frequency 0 22 16
Increased intercourse frequency 4 - -
Post-ejaculation dribble 4 - -
Ejaculatory improvement 12 - -
Decreased ejaculatory flow 4 - -
Erectile worsening noted by partner 0 33 16
Erectile improvement noted by partner 6 - -
Decreased glans sensitivity 2 - -
Overall satisfaction 100 55 83

* Dorsal plus Ventral Graft (DVG) urethroplasty
** Excision and Primary Anastomosis (EPA) for strictures 2.5 cm or less
*** Extended Anastomosis Urethroplasty (EAU) for strictures > 2.5 cm 10.
( – ) = data not available

Table 2.
Sexual complications reported in the literature following bulbar urethroplasty using anastomotic procedures.

Reference No. Pts. Sexual Complications % Complication
Morey and Kizer 200610 22 Penile curvature 44
Morey and Kizer 200610 22 Penile shortening 22
Eltahawy et al, 20072 260 Erection deterioration 2
Morey and Kizer 200610 22 Permanent complete loss of erection 18
Barbagli et al, 200711 60 Decreased ejaculation force 23
Barbagli et al, 200711 60 Glans not full during erection 11
Barbagli et al, 200711 60 Decreased penile sensitivity 18
Morey and Kizer, 200610 22 Overall satisfaction with sexual life 55

 

APPENDIX : PATIENT QUESTIONNAIRE

1) How would you describe your erections before surgery?
Absent – Not at all satisfactory – Moderately satisfactory – Very satisfactory.

2) How would you describe your erections after surgery?
Absent – Not at all satisfactory – Moderately satisfactory – Very satisfactory.

3) Has the angle of your erection changed after surgery?
Not at all – Somewhat – Quite a bit.
If so, has this symptom improved over time?
Not at all – Somewhat – Quite a bit.

4) Has the length of your penis changed since your surgery?
Not at all – Somewhat – Quite a bit.
If so, has this symptom improved over time?
Not at all – Somewhat – Quite a bit.

5) Has your partner noticed any changes in your erections since surgery?
Yes – No.

6) Have you altered your frequency of intercourse due to erection changes since surgery?
Not at all – Somewhat – Quite a bit.

7) How would you describe your health in general?
Poor – Fair – Good – Excellent.

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