One-Stage Repair of Long Bulbar Urethral Strictures Using Augmented Russell Dorsal Strip Anastomosis: Outcome of 234 Cases

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1 european urology 53 (2008) available at journal homepage: Reconstructive Urology One-Stage Repair of Long Bulbar Urethral Strictures Using Augmented Russell Dorsal Strip Anastomosis: Outcome of 234 Cases Abdel W. El-Kassaby, Tarek M. El-Zayat, Samir Azazy, Tarek Osman * Department of Urology, University of Ain-Shams, Cairo, Egypt Article info Article history: Accepted June 4, 2007 Published online ahead of print on June 11, 2007 Keywords: Reconstructive surgery Stricture Urethral reconstruction Abstract Objectives: Long bulbar urethral strictures (>2 cm) are not amenable to stricture excision and primary anastomosis procedure, which may result in a short urethra and chordee formation. For such strictures many procedures have been advocated including stricturotomy with subsequent graft or flap onlay, augmented anastomosis, and staged procedures, which is a combination of the Russell graft. We present our 10-yr experience with the augmented Russell procedure using a ventral onlay buccal mucosal patch graft for treatment of long bulbar urethral strictures not amenable to excision and primary anastomosis. Methods: A total of 234 patients diagnosed by urethrograms as having long bulbar urethral strictures (mean, 4.2 cm) were managed by the augmented Russell urethroplasty. The procedure included excision of most of the diseased segment (mean, 2.8 cm) and anastomosis of a dorsal strip leaving an oval ventral defect. Augmentation was done in all patients using a buccal mucosa patch graft (mean, 4.7 cm). Results: Mean follow-up was 36 mo. Urethrograms were done at 3 wk and 3 and 6 mo postoperatively and if the patients were symptomatic thereafter. Urethrocystoscopy was performed at 12 and 18 mo. A total of 223 patients completed the follow-up protocol; the overall success rate was 93.7% with 14 (6.3%) patients showing stricture recurrence at different intervals postoperatively. Ten patients in the failure group were successfully managed by single visualized internal urethrotomy (VIU), whereas the other four patients were treated by ventral penile pedicled flap. Postoperative dribbling of urine was noticed by 90 patients (40.4%) and temporary perioral numbness in most patients; no major donor site complications were noted in our series. Conclusion: The augmented Russell technique is beneficial for long bulbar urethral strictures; 93.7% of the patients were stricture free. In the bulbar region, both ventral and dorsal onlays are applicable with nearly equal success rates. The buccal mucosa patch graft offers excellent material for augmentation. # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. address: tarekosman77@hotmail.com (T. Osman) /$ see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 european urology 53 (2008) Introduction Stricture excision and primary anastomosis remain the first and best options in dealing with short bulbar urethral strictures (<1.5 2 cm) with excellent and durable results [1]. On the other hand, longer bulbar strictures are not amenable to this procedure, which may result in short urethra and chordee formation. For such long strictures (>2 cm) many procedures have been advocated including stricturotomy with subsequent graft or flap onlay, augmented anastomotic procedures, and staged procedures [2]. The procedure applied here is one of the augmented anastomotic procedures in which Russell s technique [3] of dorsal strip anastomosis is augmented with buccal mucosal patch graft. The application of this technique addresses many points including the state of the urethral plate, spongiofibrosis, length of the harvested grafts, chordee formation, and suitable bed for grafting. Our first report on this technique was in 1997 [4], and, herein we present our 10-yr experience in 234 cases. 2. Patients and methods Between 1995 and 2005 the augmented Russell procedure was applied for 234 patients, with a mean age of 38 yr (range: yr), presenting with long bulbar urethral strictures. The etiology was variable and included trauma in 79, inflammation in 90, iatrogenic in 33, and unknown in 32 patients. All patients were subjected to thorough history-taking, local examination of the genitalia (to assess the penile skin, meatus, scars, and palpable indurations), uroflowmetry, complete urinalysis and urine culture and sensitivity in infected cases, and retrograde and voiding urethrograms together with sonourethrography to assess the presence and extent of spongiofibrosis. The mean peak flow rate was 4.3 ml/s (range: ml/s). The urethrograms revealed a mean bulbar urethral stricture of 4.2 cm (range: 3 7 cm) and sonourethrography revealed considerable degrees of spongiofibrosis both in depth and density. Fifty-one of the patients were de novo and 183 patients received more than one attempt of visualized internal urethrotomy (VIU; 2 15 attempts). The procedure was performed under general endotracheal anesthesia with transnasal intubation and all patients were in the standard lithotomy position. A midline perineal incision was used to expose the bulbar urethra down to the bulb. A Nélaton catheter was then passed through the meatus and the site of its arrest denoted the distal end of the stricture. Circumferential dissection of the bulbar urethra from the underlying corpora with maximal proximal mobilization, followed by incision of the strictured segment guiding the lumen by a lacrimal probe or intraluminal injection of methylene blue was performed. The incision was extended both distally and proximally into the healthy urethra. Most of the fibrotic segment or the segment with markedly reduced Fig. 1 After excision of most of the fibrotic segment, the dorsal strip is anastomosed and the ventral defect is augmented by a buccal mucosa patch graft. lumen girth (<6 ch) was then excised with a mean length of 2.8 cm (range: cm); the dorsal ends were reanastomosed using 4-0 polyglactin interrupted sutures and the strip was fixed to the corpora with the penis in the full stretched state. The ventral ends remained as a spatulated ventral defect (Fig. 1). Spongioplasty was performed and the remaining healthy spongiosal tissue was meticulously sutured at the two cut ends of the excised segment (Fig. 2). The buccal mucosal graft was harvested from the lower lip in 150 cases and from the inner cheek in 84 cases, with a mean length of 4.7 cm (range: cm), sutured to the urethral mucosa using continuous 5-0 polyglactin sutures as an onlay patch (Fig. 3) over a 26 ch Nélaton catheter, and supported by interrupted full-thickness urethral sutures for better hemostasis. The remaining healthy spongiosal tissue was closed in midline over the graft and used to cover and support the graft site. However, if the spongy tissue was densely scarred and deficient, the support was only through the bulbocavernosus muscle and Colles fascia followed by skin closure with a small suction drain for 2 4 d. A silicone urethral catheter was left indwelling. Perioperative broad-spectrum antibiotics were given or according to urine culture and sensitivity if infection was present preoperatively; mobility was limited during the first 4 d for optimizing the graft take and the catheter was removed after 3 wk when a pericatheter urethrogram showed no extravasations. Oral soft meals were started after 24 h and the patient was discharged with the catheter on the fourth or fifth day. The patients were followed by subjective improvements at discharge and at 1, 3, 6, and 12 mo and then if there was a complaint thereafter. Urethrograms and uroflowmetry were performed at 3 and 6 mo and if there was a suspicion of restenosis thereafter, and urethrocystoscopy was performed at 12 and 18 mo.

3 422 european urology 53 (2008) Fig. 3 Buccal mucosal patch applied ventrally. Fig. 2 After spongioplasty, the two cut ends of the healthy spongiosal tissue are sutured. 3. Results The mean follow-up period was 36 mo (range: mo) and success was defined as normal voiding without the need for auxiliary procedures and normal urethrograms. Eleven patients were lost to complete the follow-up protocol and a total of 223 patients completed the study. No intraoperative or donor site major complications were encountered in our series, and none of the patients received a blood transfusion. The pericatheter urethrogram at 3 wk revealed a patent lumen in all patients with mild extravasations in 10 patients, which resolved by leaving the catheter for one more week. All patients voided freely after catheter removal, yet 14 (6.3%) of our early patients noted decreased stream of urine, 8 during the first 3 mo, 4 at 1 yr, and 2 at 18 mo. Urethrograms showed proximal anastomotic strictures in 10 and complete narrowing in 4 patients, and the uroflowmetry showed mean flow rates of 6.6 ml/s. Single VIU was offered to the 10 patients and no further intervention was required. The four other patients were subjected to redoing the urethroplasty using a pedicled ventral penile flap of Turner-Warwick to augment the stenotic segment; outcome was successful in all of but two patients, who had mild sacculation of the flaps, which required milking of the perineum to evacuate. Postmicturition dribbling of urine was noticed by 90 patients (40.4%); temporary perioral numbness in most of the patients resolved completely within 5 wk. No penile shortening or chordee was reported by the patients; the postoperative uroflowmetry in the successful cases (209) revealed a mean peak flow rate of 18.3 ml/s (range: ml/s) and their urethrograms were patent without diverticular formation and with normal-appearing urethral lumen and mucosa during urethrocystoscopy. The donor site showed complete healing in an average of 3 wk. The overall success rate in this series was 93.7% (209 of 223) with an additional 4.5% (10 of 223) achieving normal voiding after an additional single VIU; the remaining 1.8% (4 of 223) with complete narrowing of the repair required redo urethroplasty. 4. Discussion Urethral reconstruction is a very rich field by its variable techniques and their modifications. The awareness and malleability of such techniques points in favor of good and durable results. Long bulbar urethral strictures have been managed by several approaches, including excision with full tube replacement, stricturotomy, and flap or

4 european urology 53 (2008) graft onlay besides two-stage procedures. Each has its drawbacks and possible complications such as high incidence of anastomotic strictures with full tubes, onlay on a long diseased segment of the urethra, and a two-stage procedure [5]. We used the augmented Russell procedure by which we addressed several important points. First is the excision of all or most of the diseased urethra (maximum, 3.0 cm) making the reconstruction on a rather healthy tissue. Then by anastomosing the dorsal ends of the cut urethra we decreased the size of the graft needed for augmentation. Moreover, we used the buccal mucosa for its unique vascular network present in the lamina propria, which makes it survive better if the graft bed characteristics are suboptimal [6]. Circumferential dissection of the closed bulbar urethra makes it easier than attempting dissection after stricturotomy or excision of the diseased segment. Short bulbar urethral strictures (<2 cm) are best managed by stricturotomy and spatulated tensionfree anastomosis with success rates >95% [1]. The mean stricture length in our series was 4.2 cm; thus, such a procedure was not suitable for our patients and we used the augmented anastomotic procedure. Other smaller series reported on the same procedure with a mean stricture length of 1.5 cm [8], which we believe was too short and could have been managed safely by primary excision and anastomosis. The long strictured segment in our series did not result in any penile shortening or chordee because actually the mean excised segment was only 2.8 cm. However, the mean harvested graft length was almost similar, being 4.8 cm [7], 4.5 cm [8], and 4.7 cm in our series. We applied the ventral onlay technique with an overall success rate 93.7%, which is similar to the experience of Wessells with ventral onlay who reported a 91.6% success rate, and experiences with dorsal onlay reporting success rates of 92 97% [8 10]. These similar results confirm the debate about the optimal site of onlay. Guralnick and Webster [8] favored the dorsal onlay introduced by Barbagli et al in 1996 [11] to avoid pseudodiverticulum formation and sacculation of the graft and to offer a good bed for the graft take. However, they reported a 54% postmicturition dribbling rate that needed milking of the bulbar urethra. In our experience, in case of bulbar urethra, the ventral onlay offers a good host bed for the grafts as well, and the support is achieved by spongioplasty together with the bulbospongiosus muscle and Colles fascia and advocating dorsal onlay superiority should be in case of penile urethra [12]. In our series postmicturition dribbling was noticed in 90 patients (40.4%) and required milking of the perineum to evacuate the bulbar urethra. Yet, two patients with failure who were further treated by redoing flap urethroplasty had sacculation of the neourethra on the postoperative urethrogram. We believe that sacculation or pseudodiverticulum formation is more prone to develop with the use of pedicled flaps rather than grafts because there is always a tendency to oversize the flap dimensions. The 6.3% (14 patients) complication rate occurred in our early experience, where 10 of these patients developed a short ring anastomotic stricture at the proximal end and needed only a single VIU to remain stricture free. On the other hand, the remaining four patients developed complete narrowing of the repair, which was secondary to the long strictured segments among these patients (between 5 and 7 cm) together with dense spongiofibrosis and the paucity of the remaining urethral strip, which should have been augmented by a wider graft. All four patients were successfully managed by ventral penile pedicled flap augmentation urethroplasty. The authors long experience with the use of buccal mucosa for management of urethral stricture [13] had made it the graft of choice for long bulbar urethral stricture. Inferior results were reported using ventral full-thickness skin grafts for bulbar urethral stricture with success rate of 71 89% [14 16]. However, in the authors experience, patients not fulfilling the criteria for the augmented Russell procedure were offered other modalities of reconstruction. To our knowledge, this is the largest series reported to date using the augmented anastomotic procedure with buccal mucosa onlay. Our mean follow-up was 36 mo, which is long enough to prove successful outcome of the technique, considering that all types of urethroplasty may fail even after a considerable period [10]. 5. Conclusions Long bulbar urethral strictures can be managed by many procedures. The choice of the optimum procedure depends on many factors, with the most important being the stricture length; however, other factors include stricture etiology, previous treatment, extent of spongiofibrosis, and, of course, the surgeon s preference. At the bulbar region of the urethra, both ventral and dorsal free grafts onlay survive well with equal success rates. The buccal mucosa still proves to be the graft of choice due to its unique properties and durable results [17 19].

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