Complex Strictures

Sanjay B. Kulkarni MS, FRCS and Mang L. Chen, MD

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Redo Urethroplasty: Failed anastomotic urethroplasty for posterior urethral injuries.

    The most common cause for failure is inadequate excision of the scar at the apex of the posterior urethra.
    Unless, I see soft-to-touch, pink and mobile urethra with no white firm scar around the urethra, I do not perform the anastomosis. Hematoma and ischemia of the bulbar urethra are other causes of failure.
    A single attempt at DVIU is justified, especially in those failed urethroplasties due to an anastomotic ring.
    Longer defects need redo surgery. I often get these multiple failed urethroplasties and they pose a challenge.
    I try to do anastomotic urethroplasty with mobilization of the bulbar urethra up to the peno-scrotal junction (avoiding penile urethral mobilization) and scar excision. At times, I accept an anastomosis under tension. The other alternative of substitution urethroplasty with pedicled prepucial skin is not favored as a second choice. It leads to permanent post micturition dribble due to diverticulum formation of the deep seated skin substation.

UPDATE: long defects are now being treated by a staged approach. 1st stage involves placing buccal mucosa graft on the anterior scrotum. 2nd stage: after 10 days, the BMG flap is mobilized based on a dartos blood supply and retubularized for substitution urethroplasty. 10 days seems to be an adequate amount of time for the graft to take and for avoiding neighboring skin incorporation onto graft.

Fig. 1: Incision made in mid scrotum to expose vascular dartos fascia.


Fig. 2: BMG sewn to vascular dartos bed to be harvested 7-10 days later as a mucosal flap.


    Redo Urethroplasty: Failed BMG urethroplasty:

      The success rate of dorsal onlay buccal mucosa graft urethroplasty is around 85% (followup 4-5 yrs) so 15% patients have failed urethroplasty.
      There are three reasons for failed urethroplasty. 1) proximal anastomotic ring; 2) distal anastomotic ring; 3) the whole BMG graft is lost. For anastomotic ring recurrence, one attempt at DVIU is justified; but if it fails, a ventral onlay BMG urethroplasty gives excellent results.

    In general if one technique fails, another technique may be beneficial. That is, dorsal urethroplasty failure can be managed with ventral onlay urethroplasty or anastomotic urethroplasty.

    Rectourethral Fistula

    Those patients who present with penetrating trauma to the rectum usually need immediate repair of the rectal tear wound and a diverting colostomy. Associated pelvic fracture urethral injury will need an open or endoscopic suprapubic cystostomy. Once the patient is stabilized, he is discharged home and comes back three months later for step two.

    Step 2 is anastomotic urethroplasty with omental wrap. The approached used is the Turner-Warwick perineo-abdominal progression approach.

    Through the perineal incision, the bulbar urethra is dissected and transected; inferior pubectomy is performed if required. The surgeon inserts his left index finger into the rectum and attempt is made to close the tear in the rectum. Many times, it is not possible to close this hole but if we perform a proper anastomotic urethroplasty and wrap omentum or the Gracilis muscle between the rectum and urethra, the results are excellent. Once the patient is voiding well after catheter removal, the colostomy is closed three months later.

    Hypospadias Cripple

    These patients have multiple failed hypospadius repairs. They are left with minimal local skin for repair and have multiple strictures and or fistulae in the urethra.

    They are best dealt with two stage BMG urethroplasty. In the first stage, the whole strictured urethra is excised with all the scar tissue. The penis is made straight and its position is checked by intracavernosal injection of saline. A 2.5cm wide graft of buccal mucosa or two strips of 1.5cm wide buccal mucosa graft are spread and fixed over the corpora cavernosa. The graft is quilted with absorbable sutures. The second stage is performed 3-6 months later. A “U” incision is made and the buccal mucosa is turned into a tube. A 14F silastic Foley catheter is inserted and the skin is closed with Z plasties.

    Watering Can Perineum

    Watering can perineum is a rare complication of extensive periurethral fibrosis leading to multiple abscesses and fistulae in the perineum. These patients are continent, but when the patient voids, urine leaks out through multiple holes in the perineum.

    Fig. 3: Watering can perineum with multiple urethrocutaneous fistulas associated with lichen sclerosis strictures.


    In our series, the most common cause of watering can perineum was LS. The traditional operation described is Johanson’s two stage urethroplasty. In the first stage, the urethra is opened ventrally and the skin edges are sutured to the urethral mucosa margins. The fistulae are opened and excised.

    In the second stage, a 3cm wide “U” incision is made to tubularise the skin into urethra. During this procedure, the perineal skin on both sides of the urethral plate of the narrow urethral plate is turned into urethra inside. Use of genital skin in LS is not recommended since the failure rate of this procedure is high.

    We presented a new technique of urethroplasty for watering can perineum at the 2002 AUA meeting.

    In the first stage, the bulbar urethra is mobilized from the corpora cavernosa, opened dorsally, and the right edge of the urethra is fixed to the corpora cavernosa. The left edge of the urethra is fixed to the right edge of the skin. The left edge of the skin is fixed to the corpora cavernosa leaving a raw area 1.5cm wide on the cavernosa.

    In step two three months later, the epithelium covering the corpora cavernosa is excised and replaced by buccal mucosa graft. The left edge of the urethra is released from the right skin margin and the urethra is used as a ventral plate to cover the buccal mucosa graft placed dorsally. The skin edges are sutured to close the wound. The advantage of our technique is genital skin is not utilized intraluminally for this urethroplasty.

    Fig. 4: Note the differences between Johanson’s procedure and our technique: there will be no skin intraluminally in our staged procedure.


    Incontinence

    Bladder neck incompetence:

    In patients with pelvic fracture urethral injuries, the bladder neck may be affected directly by bone fragments. In other patients without bladder neck injury from a pelvic trauma, the rail road technique is used to pass a urethral catheter into the bladder. If traction is thereafter required to bring the bladder down, it may “dilate” the bladder neck and lead to bladder neck incompetence. Bladder neck injury is more common in children as the prostatic urethra is short in length.

    Under anesthesia, cystoscopy is performed through the suprapubic cystostomy. The normally closed circular bladder neck is evident. In case of injury to the bladder neck, we may see a tear drop deformity due to injury to the circular bladder neck fibres. As the injury is due to direct bony fragment, it is likely to be at the 12 o’clock position. Whenever we have a patient with a wide open bladder neck, it may be due to retropubic fibrosis keeping the bladder neck open or due to neurological injury. If we suspect bladder neck incompetence in a patient with posterior urethral injury, we go ahead and perform anastomotic urethroplasty first and many patients may not need surgery for incontinence. In case the patient is incontinent after successful urethroplasty, we plan bladder neck repair at the end of one year.

    Through a midline infra-umbilical incision, the bladder is opened vertically. This incision is carried through the bladder neck into the prostatic urethra. The white firm scar at the bladder neck is excised. The bladder neck is repaired in the anatomical fashion with absorbable sutures. A Foley urethral catheter is kept for 3 weeks. Results of this anatomical bladder neck repair are very encouraging. In those patients with wide open bladder neck, I have performed excision of the retropubic fibrous scar and omental wrap in few patients. But in my hands the results have not been satisfactory. In those patients who have a false passage from the bladder into the prostatic urethra, bypassing the functioning bladder neck, excision of the false passage is performed through an abdominal approach. Posterior or total pubectomy may be required to excise this epithelialized false passage. Results of this procedure are rewarding.

    Artificial sphincter may be required to control/cure incontinence as a last resort. In young men insertion of artificial sphincter around the bladder neck will give them antegrade ejaculation but may lead to impotence due to dissection around the bladder neck. Usually, the artificial sphincter is inserted around the proximal bulbar urethra.

    Overactive bladder (OAB):

      OAB is diagnosed with the symptoms of frequency, urgency and nocturia. The diagnosis is confirmed by urodynamics and the treatment is medical.

    False passage between the bladder and the urethra bypassing sphincter mechanism:

        This will lead to incontinence of urine. These false passages are a result of the rail road technique or core-through urethrotomy, creating a false connection between the bulbar urethra and the bladder. Most of these patients need redo surgery with excision of the false passage and redo bulbo prostatic anastomosis. If the false passage is anterior to the prostate, one may have to perform surgery through a suprapubic incision, and partial or total pubectomy may be necessary.

      Lichen Sclerosis/BXO

      Balanitis Xerotica Obliterans (BXO) is a skin disease of the genitalia. Dr. Stuhner described BXO in 1928. Lichen Sclerosus (LS) is a chronic inflammatory skin disease of unknown origin and its pathogenesis has not yet been completely characterized. In 1995, the American Academy of Dermatologists recommended that the term LS should be used in future reports to define the true incidence and malignant potential of LS. LS in a male genital area may cause destructive scaring that can lead to devastating urinary and sexual problems and a dramatic reduction in quality of life. Involvement of foreskin and the external urinary meatus is frequently reported in boys and adults. The difficult circumcision one encounters is usually due to LS. It is also reported that patients with failed hypospadias repair have a high incidence of LS.

      LS may present at an early stage where the disease is limited to foreskin, and circumcision is a treatment of choice. At a later stage, the patient may present with meatal stenosis and the treatment is meatotomy and meatoplasty. Ventral meatotomy and meatoplasty may give temporary relief. Urologists are using genital skin with simple meatotomy and meatoplasty, leading to higher chances of recurrence. Instead of skin, we prefer dorsal meatotomy and a buccal mucosa graft placed dorsally. Our long term results are more than satisfactory.

      Fig. 5: Patient has characteristic findings of BXO/lichen sclerosis: hypopigmentation, meatal stenosis, and scarring of penile shaft skin to corona of glans.


      Fig. 6: RUG showing proximal pan-urethral stricture.


      LS may present with penile urethral stricture. Various options are described in the literature. Use of genital skin as an Orandi flap is not advocated since the recurrence rate is high, as mentioned before. Some advocate excision of the scarred penile urethra followed by buccal mucosa graft in the first stage. In the second stage the buccal mucosa is turned into a tube. This two stage reconstruction of the penile urethra is preferred by many reconstructive urologists. Our experience of two stage buccal mucosa graft urethroplasty is not good. In India, the buccal mucosa graft shrinks and leaves a scarred buccal mucosa plate and the second stage reconstruction of the tube is difficult. Furthermore, the complication rate (i.e. fistula, stricture recurrence, etc) approaches 50%.

      Our method of choice for the treatment of penile urethral strictures due to LS is the Kulkarni panurethral one-sided dorsal onlay Technique. The late presentation of LS is in the form of full length strictures of the penile and bulbar urethra. These patients may have undergone multiple failed urethroplasties, multiple DVIUs, multiple dilations. Circumferential fasciocutaneous flaps of the prepuce and the penile skin have been used as ventral or dorsal augmentation urethroplasty, but the recurrence rate is high since it’s skin. As mentioned before, two stage Johansson’s urethroplasty is used by some. In the first stage the urethra is opened ventrally and the edge of the urethra is sutured to the skin edge on both sides. Three to six months later, a “U” incision is made and a new urethral tube is constructed. If the urethral plate was 10mm wide then 10mm skin on each side of the urethra is used to make a 30mm wide urethra forming 30 F urethral tube. This use of genital skin leads to high recurrence rate. We advocate the use of the “Kulkarni Technique” for full length strictures of the urethra due to LS. The success rate of this urethroplasty is excellent in the long term (please see article “pan urethral one-sided dorsal onlay urethroplasty”).

      Fig. 7: Penis invaginated and dorsal onlay BMG is placed on corpora. (Details seen on video link on above tab or in article “panurethral stricture one-sided repair”.)


      Urethral Cancer

      Squamous cell carcinoma of the urethra is rare. I have seen only five patients with squamous carcinoma in the last twenty years of my practice, and all patients had lichen sclerosus as a precancerous disease. All patients presented with a lump in the perineum. In two patients the lumps were incised by urologists who that they were periurethral abscesses. Two patients were referred after first stage Johansson’s urethroplasty for non-healing of the wound. One patient was diagnosed on endoscopy.

      Fig. 8: Squamous cell cancer presenting as “non-healing wound” from the perineum. Notice that the patient has obvious BXO of the glans.


      Traditional treatment for penile urethral cancer will be decided by the local extent of the disease and may vary from wide local excision to partial or total amputation of the penis. For bulbar urethral cancer, depending upon the local invasion, wide local excision and or total amputation of the penis may be required. For large bulbar urethral cancers and posterior urethral cancers, traditional treatment involves total amputation of penis with cystoprostatourethrectomy and lymph node dissection, and the patient needs urinary diversion (i.e. ileal conduit). The local recurrence rate after such a major operation is very high. Five year survival is less than 20% ,so 80% patients may die because of local recurrence and its problems.

      Fig. 9: Penectomy specimen from squamous cell cancer of the urethra.


      In two patients, I have utilized a new technique of wide local excision followed by neo-urethra formation with the dorsal penile skin. Under anesthesia, a circumcision incision is made, preserving the dorsal penile skinwith the its fascia far away from the side of the cancer. Total amputation of the penis with bilateral orchiectomy (with spermatic cord involvement) is performed in the traditional way. Since the patient may have had a perineal incision for urethroplasty, percutaneous biopsy, or perineal drainage (thinking it is a periurethral abscess), perineal skin use may not be possible.

      Fig. 10: Neourethra formed by tubularization of the remaining penile skin.


      In one patient, the prostate also was removed. Biopsies from the bladder neck were normal. For prostate removal, inferior pubectomy was useful to control the dorsal vein complex. The bladder neck was preserved and was completed. If I introduced a forceps inside the bladder neck, urine flowed out freely, but as soon as I removed the forceps urine leak stopped immediately. Now the dorsal penile skin was turned into a tube with skin as its inner lining. It was anastomosed to the bladder neck. The patient voided well and was continent. In the second patient, we had taken biopsies from the prostatic urethra which were normal, so we could preserve the prostate and anastomose the new urethra to the apex of the prostatic urethra. One patient died within six months due to local recurrence, but one patient has survived for more than a year and is still free from recurrence. This new technique of wide local excision and neo urethra creation allows the patient to void via the perineum and it provides continence. In addition, it prevents major surgery with ileal conduit creation.

      Fig. 11: Postoperative picture after creation of penile skin urethra. Patient can void via his perineum and is continent.


      References

      • Mundy AR, Andrich DE. Entero-urethroplasty for the salvage of bulbo-membranous stricture disease or trauma. BJU Int. 2010 Jun;105(12):1716-20. PubMed PMID:19930173.

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