Male and Female Urethral Reconstruction: From Simple to Complex

The instructional course on urethral stricture disease was held September 3, 2007 at the centennial congress of the Societe Internationale Urologie in Paris. It was chaired by Richard Santucci from Wayne State in Detroit.

Richard Santucci began the session with “A Simplified, Unified Approach to Urethral Stricture Disease”. Although Richard has utilized 22 different urethroplasty techniques for the treatment of stricture disease in his practice, he believes that he can achieve great results with the use of only four.

The first is buccal mucosa urethroplasty, either ventral in the bulbar urethra or dorsal in the pendulous urethra. He has abandoned the use of the anastomotic or end-to-end urethroplasty (EPA) due to concerns over an increased incidence of new onset erectile dysfunction (anywhere from 14-26%) and the development of chordee in 6% of cases. His recurrence rate with EPA was 7% and 0% with bulbar urethroplasties.

Procedure number 2 is the first and second stage Johanson urethroplasties which are indicated when inadequate penile skin is present for other repairs or those strictures too long for buccal mucosa repairs. These repairs are used to temporize the toughest strictures and, in many cases, patients choose not to go ahead with second stages. Some tips of successful repair include making a 3cm dorsal urethral plate, almost always leaving the diseased urethral plate and augmenting it with buccal mucosa, and to make every attempt to spare the ventral glans if possible and to tunnel repairs under this instead. He also gave some points about perineal urethrostomy and urges a side perineal urethrostomy to be performed instead of an end perineal urethrostomy due to a very high rate of stenosis of the latter.

Procedure 3 is the anastomotic urethroplasty used for pelvic fracture distraction defects. This procedure was discussed in great detail by the second speaker of the session. The fourth procedure, the circular fasciocutaneous flap urethroplasty, seems soon to leave Richard’s armamentarium also as he reports a failure rate of 20-40% which he is dissatisfied with. He also again condemned the use incisional urethrotomy and dilation unless palliation is the only goal as the success rate for the second and third attempt in even the best strictures is near 100%.

Next Sanjay Kulkarni from Pune, India discussed “Posterior Urethral Distraction Injury: Practical Issues fro Treatment of the Most Devastating Injuries”. He began with a continuation of the debate about delayed management versus an attempt at primary realignment. Quoting stricture rates of 5#% and a 36% incidence of ED, he continues to recommend the use of immediate suprapubic urinary diversion followed by delayed reconstruction at 3-6 months after the injury. He does admit that primary realignment may be useful to shorten severely distracted injuries and allow the urethral ends to more in plane at the time of delayed repair. He makes a point of documenting erectile status pre-operatively and does so by history and the use of duplex Doppler ultrasonography. He also utilizes pre-operative CT scanning if he suspects the presence of bone fragments within the bladder. He utilizes the four-step approach to reduce the length between the urethral ends with step one being mobilization of the urethra from the cavernosal bodies up to the peno-scrotal junction, step two consisting of separation of the crural bodies, step three being inferior pubectomy, and four, the very infrequently used urethral re-routing around the crura. Extremely rarely, a transpubic repair is used and in these cases, omental wrapping of the anastomosis is recommended. Expected success rates are around 90% with the vast majority of failures occurring in the first six months. Failures are usually anastomotic ring strictures that occur because of inadequate scar excision. Lastly, when these injuries occur in females, he employs a dorsal suprameatal approach and has a high index of suspicion for a concomitant bladder injury with the finding of bony fragments within the bladder.