Urethroplasty

Last updated
Urethroplasty
Specialty urology

Urethroplasty is the surgical repair of an injury or defect within the walls of the urethra. Trauma, iatrogenic injury and infections are the most common causes of urethral injury/defect requiring repair. Urethroplasty is regarded as the gold standard treatment for urethral strictures and offers better outcomes in terms of recurrence rates than dilatations and urethrotomies. It is probably the only useful modality of treatment for long and complex strictures though recurrence rates are higher for this difficult treatment group. [1]

Contents

There are four commonly used types of urethroplasty performed; anastomotic, buccal mucosal onlay graft, scrotal or penile island flap, and Johansen's urethroplasty. [2]

With an average operating room time of between three and eight hours, urethroplasty is not considered a minor operation. Patients who undergo a shorter duration procedure may have the convenience of returning home that same day (between 20% and 30% in total of urethroplasty patients). Hospital stays of two or three days duration are the average. More complex procedures may require a hospitalization of seven to ten days. [3]

Phases of the operation

These parts of the operation are common to all specific operations.

Preoperative

Ideally, the patient will have undergone urethrography to visualize the positioning and length of the defect. The normal pre-surgical testing/screening (per the policies of the admitting hospital, anesthesiologist, and urological surgeon) will be performed, and the patient will be advised to ingest nothing by mouth, "NPO", for a predetermined period of time (usually 8 to 12 hours) prior to the appointed time.[ citation needed ]

Upon arrival to the preoperative admitting area, the patient will be instructed to don a surgical gown and be placed into a receiving bed, where monitoring of vital signs, initiation of a normal saline IV drip, and pre-surgical medication including IV antibiotics, and a benzodiazepine class sedative, usually diazepam or midazolam will be started/administered. [4]

Operative

The patient will be transported to the operating room and the procedures for induction of the type of anesthesia chosen by both the patient and medical staff will be started. The subject area will be prepped by shaving, application of an antiseptic wash (usually povidone iodine or chlorhexidine gluconate - if sensitive or allergic to the former), surgically draped and placed in the Lloyd-Davies position. Note: throughout the duration of the procedure, the patient's legs will be massaged and manipulated at predetermined intervals in an attempt to prevent compartment syndrome, a complication from circulatory and nerve compression resultant from the lithotomy positioning. Some hospitals utilize the Allen Medical Stirrup System, which automatically inflates a compression sleeve applied to the thigh-portion of the stirrup device at predetermined intervals. This system is designed to prevent compartment syndrome in surgeries lasting more than six hours. [3]

At this time the surgical team will perform testing to determine if the anesthesia has taken effect. Upon satisfactory finding(s), a suprapubic catheter (with drainage system) will be inserted into the urinary bladder (to create urinary diversion during the procedure), and the chosen procedure will then be initiated. [3]

Note: The surgical procedures listed below may have small variances in the methodology used from surgeon to surgeon. Consider the following as a generalized description of each individual procedure, although every precaution was taken to ensure the accuracy of the information.[ citation needed ]

Types of operations

The choice of procedure is dependent on factors including: [2]

Note: in more complex cases, more than one type of procedure may be performed, especially where longer strictures exist.

Anastomotic urethroplasty

In this single-stage procedure the urethra will be visualized (in the area of the defect), and the incision will be started at its mid-line (usually) using a bovie knife to dissect the dermal and sub-dermal layers until the associated musculature, corpus cavernosum, corpus spongiosum, and ventral urethral aspects are exposed. Particular care is used during the dissection to prevent damage to nerves and blood vessels (which could result in erectile dysfunction or loss of tactile sensation of the penis). The area of the defect is evaluated and marked both mid-line (laterally), and at the distal and proximal borders (transversely). Marked/labeled positioning sutures are secured (one, each) at the proximal and distal ends of the mid-line area of urethra closest to the bisection points. Using an index finger, the urethra is gently separated from the cavernosum, and a specially designed retractor is then placed behind the urethra (to protect vulnerable areas from damage during the transecting and removal of the urethral defect. The now patent ends of the urethra are prepared using a technique called "spatulation", which (essentially) allows for the end-to-end anastomosis to adjust to the differing diameters of the urethra. A silicone catheter is inserted through the penis and (temporary) distal-urethral end, and threaded into the (temporary) proximal-urethral end, leaving a wide loop for the surgeon to have access to the dorsal urethral aspect for micro-suturing, and start of the anastomosis. The dorsal one-third of the urethral anastomosis is begun, completed, and the catheter is retracted slightly to allow for its positioning within the pre-anastomosed urethra. At this time, using micro surgical technique, the anastomosis is completed and fibrin glue is applied to the anastomotic suture line to help prevent leakage and fistula formation. The silicone guide catheter will then be withdrawn from the penis and (a) replaced by an appropriately sized Foley catheter (and urinary drainage system), and the incision closed (layer by layer). Some surgeons will inject a local anesthetic such as 2% plain lidocaine or 0.5% bupivicaine into the areas to allow the patient an additional period of relief from discomfort. [5]

Micro-doppler circulatory measurement of the penile vasculature is performed at way points throughout the procedure, and a final assessment is taken and recorded. The incision is inspected and dressed, and the patient is discharged to recovery.[ citation needed ]

(a) some surgeons prefer the use of a suprapubic catheter, as they believe insertion of an in-dwelling urethral catheter may damage the anastomosed area[ citation needed ]

Expected average success rate: The success rate for this procedure is above 95%, anastomotic urethroplasty is considered the "gold standard" of surgical repair options. It is generally used when strictures are less than 2 cm in length, however, some surgeons have had success with defects approaching 3 cm in length. [6] [7] [8]

Buccal mucosal onlay graft of the ventral urethra

In this single-stage procedure the urethra will be visualized (in the area of the defect), and the incision will be started at its mid-line (usually) using a bovie knife to dissect the dermal and sub-dermal layers until the associated musculature, corpus cavernosum, corpus spongiosum, and ventral urethral aspects are exposed. (a) Particular care is used during the dissection to prevent damage to nerves and blood vessels (which could result in erectile dysfunction or loss of tactile sensation of the penis). The area of the defect is evaluated and marked laterally mid-line, and (marked) positioning sutures are positioned (one, each) at the proximal and distal ends of the area of urethra closest to border of the defective area. Simultaneously, a urological surgeon who is specifically trained in buccal mucosal harvesting techniques will begin harvest and repair of a section of the inside cheek of the patient, corresponding to the dimension/shape calculated and requested by the surgeon performing the urethral aspect of the procedure. When available, an oral/maxillofacial surgeon or ENT specialist will harvest the buccal mucosa in accordance with those requested specifications. Upon retrieval, the buccal graft is presented to the urethral surgeon, who will then prepare the graft by trimming and removal of extraneous tissue.[ citation needed ]

The surgeon will create an incised opening laterally between the known outer borders of the defect, retract the incised opening to the desired diameter, and position the graft to cover the incision. This will form a tunnel, or diversion through the stricture which is 10 mm (optimally) in estimated diameter, to allow for the flow of urine. Using micro surgical techniques, the buccal graft will be sutured in place and fibrin glue applied to the suture line to prevent leakage and formation of a fistula. At this time an appropriately sized (a) Foley catheter will be inserted through the repair and into the bladder (and connected to a urinary drainage system), and the incision closed (layer by layer). Some surgeons will inject a local anesthetic such as 2% plain lidocaine or 0.5% bupivicaine into the areas to allow the patient an additional period of relief from discomfort. [9]

Micro-doppler circulatory measurement of the penile vasculature is performed at way points throughout the procedure, and a final assessment is taken and recorded. The incision is inspected and dressed, and the patient is discharged to recovery.

(a) At this time, some surgeons prefer to insert a safety guide (as used in urethrotomy) from the urinary meatus, through the stricture, and into the bladder for purposes of maintaining positioning.

(b) some surgeons prefer the use of a suprapubic catheter, as they believe insertion of an in-dwelling urethral catheter may damage the surgically repaired area.

Expected average success rate: The success rate for this procedure is between 87 and 98%, buccal mucosal onlay urethroplasty is considered the best of repair options for strictures greater than 2 cm in length. Within recent years, surgeons have been applying the onlay to the dorsal aspect of the urethra with great success. Buccal mucosa best approximates the tissue which composes the urethra. [6]

Scrotal or penile island flap (graft) of the ventral urethra

In this single-stage procedure the urethra will be visualized (in the area of the defect), and the incision will be started at its mid-line (usually) using a bovie knife to dissect the dermal and sub-dermal layers until the associated musculature, corpus cavernosum, corpus spongiosum, and ventral urethral aspects are exposed. (a) Particular care is used during the dissection to prevent damage to nerves and blood vessels (which could result in erectile dysfunction or loss of tactile sensation of the penis). The area of the defect is evaluated and marked laterally mid-line, and (marked) positioning sutures are positioned (one, each) at the proximal and distal ends of the area of urethra closest to border of the defective area. The surgeon will then harvest a section of tissue from the scrotum or penile foreskin (or what remains in circumsised males) corresponding to the previously determined dimension/shape. Upon retrieval, the graft is prepared for attachment by trimming and removal of extraneous tissue.[ citation needed ]

The surgeon will create an incised opening laterally between the known outer borders of the defect, retract the incised opening to the desired diameter, and position the graft to cover the incision. This will form a tunnel, or diversion through the stricture which is 10 mm (optimally) in estimated diameter, to allow for the flow of urine. Using micro surgical techniques, the scrotal graft or penile island flap will be sutured in place and fibrin glue applied to the suture line to help prevent leakage and formation of a fistula. At this time an appropriately sized (b) Foley catheter will be inserted through the repair and into the bladder (and connected to a urinary drainage system), and the incision closed (layer by layer). Some surgeons will inject a local anesthetic such as 2% plain lidocaine or 0.5% bupivicaine into the areas to allow the patient an additional period of relief from discomfort. [10]

Micro-doppler circulatory measurement of the penile vasculature is performed at way points throughout the procedure, and a final assessment is taken and recorded. The incision is inspected and dressed, and the patient is discharged to recovery.

(a) At this time, some surgeons prefer to insert a safety guide (as used in urethrotomy) from the urinary meatus, through the stricture, and into the bladder for purposes of maintaining positioning.

(b) some surgeons prefer the use of a suprapubic catheter, as they believe insertion of an in-dwelling urethral catheter may damage the surgically repaired area

Expected average success rate: The success rate for this procedure is between 70% and 85%, scrotal or penile island flap urethroplasty is considered the least attractive of repair options for urethral defects, it is, however, the standard procedure used in the repair of strictures greater than 4 cm in length. As with the buccal mucosal onlay, surgeons have been performing the dorsal aspect procedure since the late 1990s, with an estimated success rate approaching 90%. [6]

Johansen's urethroplasty

The Johansen's procedure sometimes referred to as "Johanson's urethroplasty" is a two-stage procedure which was developed during the 1950s and 1960s by Swedish surgeon Dr. Bengt Johansen, and was originally designed as a surgical repair for hypospadias. Over the years, the surgery has evolved into a fairly complex operation whereby the damaged area of the urethra is opened ventrally and left open as a buried skin strip with a deep diversion created from scrotal or penile skin covering the area of the repair. An appropriately sized in-dwelling catheter is inserted, and the repaired area is temporarily closed (sutured in some locations, with packing and dressings in others) until the newly created diversion forms completely, usually within six months. Upon the confirmation of completed healing, the catheter is withdrawn and the surgical site closed permanently. There are numerous methods attributed to the name "Johansen's". Most severe urethral trauma is reconstructed using the Johansen's urethroplastic procedure. It is also the procedure normally utilized in the repair of damage caused by balanitis lichen sclerosus, also referred to as balanitis xerotica obliterans. [11]

The Johansen's procedure is used in the most difficult of traumatic reconstruction cases. Because of the variations of practice within this procedure, an estimated success rate is not available.[ citation needed ]

Post-procedural care

Constant monitoring of vital signs including pulse oximetry, cardiac monitoring (ECG), body temperature and blood pressure are carried out by the anesthesia practitioner until the patient is discharged post-operatively to the post-surgical recovery unit. After sufficient awakening from the anesthetic agent has taken place, and if the patient is a candidate for same day discharge, he (and the person responsible for his transport home) will be instructed in the care and emptying of the catheter and its drainage system, cleansing of the involved area(s) and methods/intervals for dressing change, monitoring for signs of infection and for signs of catheter blockage. The patient will be given prescriptions for an antibiotic or anti-infective agent, a urinary anti-spasmodic, and a mild to moderate pain medication (no more than a few days worth of pain is expected). The patient will be instructed to optimize bed rest for the first two days after the operation, be limited to absolutely no lifting, and instructed to consume a high fiber diet and use a stool softener such as polyethylene glycol to help in avoiding straining during evacuation. After days 1 and 2, the patient will be instructed to sensibly increase physical activity, and avoid becoming sedentary. Adequate hydration is essential during the post-recovery phase of the procedure. [3]

In accordance with the preference of the surgeon, a retrograde urethrogram will be scheduled to coincide with the anticipated removal date of the suprapubic or Foley catheter (usually 7 to 14 days post-procedure, however some surgeons will attempt removal in 3 to 5 days). [12] At 10 days post procedure, the suture line(s) will be evaluated, and the sutures removed if applicable (in many cases, the surgeon will utilize absorbable sutures, which do not require removal). [3]

The length of hospitalization is usually determined by the: [3]

Possible post surgical complications

Note: Urethroplasty is generally well tolerated with a high rate of success, serious complications occur in fewer than ten percent of patients though complications particularly recurrences are commoner in long and complex strictures. [1] [13] [8]

Research

Urethrotomy vs. urethroplasty

Comparing the two surgical procedures, a UK trial found that both urethrotomy and urethroplasty are effective in treating urethral stricture in the bulbar region. At the same time the more invasive urethroplasty had longer-lasting benefit and was associated with fewer re-interventions. [14] [15] The results were integrated into the new UK guidelines on the treatment urethral narrowing by British Association of Urological Surgeons. [16]

Related Research Articles

<span class="mw-page-title-main">Urethra</span> Tube that connects the urinary bladder to the external urethral orifice

The urethra is a tube that connects the mammalian urinary bladder to the urinary meatus. Male and female placental mammals release urine through the urethra during urination, but males also release semen through the urethra during ejaculation.

<span class="mw-page-title-main">Urethral stricture</span> Medical condition

A urethral stricture is a narrowing of the urethra, the tube connected to the bladder that allows the passing of urine. The narrowing reduces the flow of urine and makes it more difficult or even painful to empty the bladder.

<span class="mw-page-title-main">Hypospadias</span> Medical condition

Hypospadias is a common variation in fetal development of the penis in which the urethra does not open from its usual location on the head of the penis. It is the second-most common birth defect of the male reproductive system, affecting about one of every 250 males at birth. Roughly 90% of cases are the less serious distal hypospadias, in which the urethral opening is on or near the head of the penis (glans). The remainder have proximal hypospadias, in which the meatus is all the way back on the shaft of the penis, near or within the scrotum. Shiny tissue that typically forms the urethra instead extends from the meatus to the tip of the glans; this tissue is called the urethral plate.

Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It may correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

<span class="mw-page-title-main">Urinary retention</span> Inability to completely empty the bladder

Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.

<span class="mw-page-title-main">Prostatectomy</span> Surgical removal of all or part of the prostate gland

Prostatectomy is the surgical removal of all or part of the prostate gland. This operation is done for benign conditions that cause urinary retention, as well as for prostate cancer and for other cancers of the pelvis.

<span class="mw-page-title-main">Suprapubic cystostomy</span> Surgical procedure to drain urine

A suprapubic cystostomy or suprapubic catheter (SPC) is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow. The connection does not go through the abdominal cavity.

<span class="mw-page-title-main">Radical retropubic prostatectomy</span>

Radical retropubic prostatectomy is a surgical procedure in which the prostate gland is removed through an incision in the abdomen. It is most often used to treat individuals who have early prostate cancer. Radical retropubic prostatectomy can be performed under general, spinal, or epidural anesthesia and requires blood transfusion less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as urinary incontinence and impotence, but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.

A urethrotomy is an operation which involves incision of the urethra, especially for relief of a stricture. It is most often performed in the outpatient setting, with the patient (usually) being discharged from the hospital or surgery center within six hours from the procedure's inception.

<span class="mw-page-title-main">Retrograde urethrogram</span> Medical imaging of the urethra

A retrograde urethrography is a routine radiologic procedure used to image the integrity of the urethra. Hence a retrograde urethrogram is essential for diagnosis of urethral injury, or urethral stricture.

<span class="mw-page-title-main">Urethrostomy</span>

Urethrostomy is a surgical procedure that creates a permanent opening in the urethra, commonly to remove obstructions to urine flow. The procedure is most often performed in male cats, where the opening is made in the perineum.

<span class="mw-page-title-main">Buried penis</span> Male congenital condition

Buried penis, also called hidden penis or retractile penis, is a congenital or acquired condition in which the penis is partially or completely hidden below the surface of the skin. A buried penis can lead to urinary difficulties, poor hygiene, infection, and inhibition of normal sexual function.

Bulbar urethral necrosis is a problem that can occur after a pelvic fracture associated urethral distraction defect (PFUDD).

<span class="mw-page-title-main">Georges Marion</span> French surgeon and urologist

Georges Marion was a French surgeon and urologist.

<span class="mw-page-title-main">Webbed penis</span> Medical condition

Webbed penis also known as buried or concealed penis is an acquired or congenital condition in which the scrotal skin extends onto the ventral penile shaft. The penile shaft is buried in the scrotum or tethered to the scrotal midline by a fold or web of skin. The urethra and erectile bodies are usually normal. Webbed penis is usually asymptomatic, but the cosmetic appearance is often unacceptable. This condition may be corrected by surgical techniques.

<span class="mw-page-title-main">Artificial urinary sphincter</span> Medical device

An artificial urinary sphincter (AUS) is an implanted device to treat moderate to severe stress urinary incontinence, most commonly in men. The AUS is designed to supplement the function of the natural urinary sphincter that restricts urine flow out of the bladder.

A penile injury is a medical emergency that afflicts the penis. Common injuries include fracture, avulsion injury, strangulation, entrapment, and amputation.

The genitourinary tract, or simply the urinary tract, consists of the kidneys, ureters, bladder, and the urethra. The kidney is the most frequently injured. Injuries to the kidney commonly occur after automobile or sports-related accidents. A blunt force is involved in 80-85% of injuries. Major decelerations can result in vascular injuries near the kidney's hilum. Gunshots and knife wounds and fractured ribs can result in penetrating injuries to the kidney.

Transvaginal mesh, also known as vaginal mesh implant, is a net-like surgical tool that is used to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI) among female patients. The surgical mesh is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder.

Kamran Ahmed is a Professor and a Urological Surgeon who is affiliated with Sheikh Khalifa Medical City, Abu Dhabi, UAE, Khalifa University, Abu Dhabi and King's College London, United Kingdom.

References

  1. 1 2 Bello, Jibriloyekunle (2016). "Impact of preoperative patient characteristics on posturethroplasty recurrence: The significance of stricture length and prior treatments". Nigerian Journal of Surgery. 22 (2): 86–89. doi: 10.4103/1117-6806.188979 . PMC   5013748 . PMID   27843271.
  2. 1 2 "Urethral strictures and their surgical treatment". Bio-Info Bank.
  3. 1 2 3 4 5 6 Gratia M. Nagle; James R. Bollinger (1997). Genitourinary surgery . Mosby, 1997. ISBN   978-0-8151-7029-7.
  4. ↑ "Recommendations and Guidelines for Preoperative Evaluation" (PDF). University of Nebraska Medical Center, Tinker, John H., M.D.
  5. ↑ "Anastomotic urethroplasty, principles and practice" (PDF). The Center for Reconstructive Urethral Surgery.
  6. 1 2 3 Eltahawy, Ehab A.; Virasoro, Ramón; Schlossberg, Steven M.; McCammon, Kurt A.; Jordan, Gerald H. (2007). "Long-term Follow up for Excision and Primary Anastomosis for Anterior Urethral Strictures" (PDF). The Journal of Urology. 177 (5): 1803–1806. doi:10.1016/j.juro.2007.01.033. PMID   17437824.
  7. ↑ "Urethral stricture disease - treatment information". The Center for Reconstructive Urology.
  8. 1 2 Santucci, Richard A.; Mario, Layla A.; Aninch, Jack W. M c. (2002). "Anastomotic Urethroplasty for Bulbar Urethral Stricture: Analysis of 168 Patients". The Journal of Urology. 167 (4): 1715–1719. doi:10.1016/S0022-5347(05)65184-1. PMID   11912394.
  9. ↑ "Buccal Mucosal Urethral Graft, how to do it" (PDF). The Center for Reconstructive Urethral Surgery.
  10. ↑ El-Kasaby, Abdel Wahab; El-Beialy, Hatem; El-Halaby, Rafik; Nowier, Amr; Maged, Aly (1986). "Urethroplasty Using Transverse Penile Island Flap for Hypospadias". The Journal of Urology. 136 (3): 643–644. doi:10.1016/s0022-5347(17)45002-6. PMID   3735540.
  11. ↑ Al-Ali, M.; Al-Hajaj, R. (2001). "Johanson's Staged Urethroplasty Revisited in the Salvage Treatment of 68 Complex Urethral Stricture Patients: Presentation of Total Urethroplasty". European Urology. 39 (3): 268–271. doi:10.1159/000052451. PMID   11275717. S2CID   46762992.
  12. ↑ Al-Qudah, H. S.; Cavalcanti, A. G.; Santucci, R. A. (2005). "Early catheter removal after anterior anastomotic (3 days) and ventral buccal mucosal onlay (7 days) urethroplasty" (PDF). International Brazilian Journal of Urology. 31 (5): 459–63, discussion 464. doi: 10.1590/s1677-55382005000500007 . PMID   16255792.
  13. ↑ Arthur D. Smith; Gopal H. Badlani; Demetirus H. Bagley; Ralph V. Clayman; Steven G. Docimo. "Smith's Textbook of Endourology". PMPH - USA.[ dead link ]
  14. ↑ "Men with urethral narrowing can be offered a choice of effective surgery". NIHR Evidence (Plain English summary). National Institute for Health and Care Research. 2020-12-18. doi:10.3310/alert_43436. S2CID   241410809.
  15. ↑ Goulao, Beatriz; Carnell, Sonya; Shen, Jing; MacLennan, Graeme; Norrie, John; Cook, Jonathan; McColl, Elaine; Breckons, Matt; Vale, Luke; Whybrow, Paul; Rapley, Tim; Forbes, Rebecca; Currer, Stephanie; Forrest, Mark; Wilkinson, Jennifer (13 September 2020). "Surgical Treatment for Recurrent Bulbar Urethral Stricture: A Randomised Open-label Superiority Trial of Open Urethroplasty Versus Endoscopic Urethrotomy (the OPEN Trial)". European Urology. 78 (4): 572–580. doi:10.1016/j.eururo.2020.06.003. hdl: 2164/16774 . PMID   32636099. S2CID   220412303.
  16. ↑ Bugeja, Simon; Payne, Stephen R.; Eardley, Ian; Mundy, Anthony R. (18 June 2020). "The standard for the management of male urethral strictures in the UK: a consensus document". Journal of Clinical Urology. 14 (1): 10–20. doi:10.1177/2051415820933504. ISSN   2051-4158. S2CID   225765110.


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