Dorsal or ventral placement of the preputial/penile skin onlay ap for anterior urethral strictures: does it make a difference?

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1 BJU Interntionl (2001), 88, 39±43 Dorsl or ventrl plcement of the preputil/penile skin only p for nterior urethrl strictures: does it mke difference? M. BHANDARI, D. DUBEY nd B.S. VERMA Deprtment of Urology nd Renl Trnsplnttion, Snjy Gndhi Postgrdute Institute of Medicl Sciences, Lucknow, Indi Ojective To report our experience in mnging complex nterior urethrl strictures with dorslly/dorsolterlly plced penile/preputil vsculrized p, nd to discuss the dvntges of this procedure over trditionl ventrlly plced p. Ptients nd methods Between 1995 nd 1999, 40 ptients (men ge 40.5 yers) with recurrent strictures of the pendulous nd/or ulr urethr were treted with longitudinl penile/circumpenile p sustitution urethroplsty. Nineteen ptients underwent dorsl plcement of the p s n only (DO), wheres 21 ptients hd ventrl only (VO). Five ptients needed inferior puectomy to fcilitte high proximl plcement of the p. Results Both groups hd sttisticlly similr ges, numer of previous interventions, stricture site, length nd follow-up. After medin follow-up of 27.5 months, the stricture recurred in three (24%) of the VO nd two (11%) of the DO groups (P>0.05). One ptient in the VO group required surgicl closure of the urethrl stul. Flp pseudo-diverticulum nd/or sccultion with postvoid drile occurred in six ptients in the VO nd none in the DO group (P=0.01). Conclusions Dorsl plcement of the pedicled p is ntomiclly nd functionlly more pproprite thn the trditionl VO plcement. DO preputil/penile p urethroplsty is verstile procedure nd cn e pplied even for long nterior urethrl strictures, including reconstruction of the metus nd high proximl ulr strictures. Keywords penile p, urethrl stricture, dorsl p urethroplsty, ventrl p urethroplsty Introduction Anterior urethrl strictures which cnnot e excised nd re-nstomosed re est treted y sustitution urethroplsty with either preputil/penile skin ps or free grfts of ldder/uccl mucos or non hir-ering skin [1]. Flps re preferred to grfts in long, recurrent strictures [2]. These urethrl sustitutes re trditionlly plced on the ventrl spect of the stricture nd hve success rte of < 85% [3]. However, ventrlly plced grfts, eing unsupported, led to sgging, sccultion nd diverticulum formtion with resultnt stsis, postvoid drile nd recurrent UTIs [4±7]. Recently, dorsl plcement of the free grft hs een descried, llowing the skin ptch/ uccl mucos to e spred nd xed on the tunic lugine of the corporl odies overlying the strictured segment of the urethr [8]. This loction offers etter outcome, decresed incidence of grft shrinkge, outpouching nd diverticulum formtion, with promising short-term results [9,10]. Accepted for puliction 5 April 2001 We used the pedicled penile/preputil p on the dorsl spect s n only for mnging complex recurrent nterior urethrl strictures, nd compred it with the trditionl ventrlly plced ps. Ptients nd methods Between July 1995 nd Jnury 1999, 40 ptients presented with recurrent urethrl strictures involving the ulr nd/or pendulous urethr. All ptients hd undergone multiple previous internl urethrotomies nd/or urethrl dilttions. In ddition ve ptients hd filed perinel end-to-end urethroplsty undertken elsewhere. Sixteen ptients hd suprpuic cystostomy plced t the time of presenttion. In 24 ptients the men (rnge) pek ow rte ws 6.2 (4±9) ml/s. Nineteen ptients were treted with dorsl/dorsolterl only preputil/penile p urethroplsty (DO) wheres 21 underwent trditionl ventrl only (VO) procedure. The men ge, stricture site, length nd the numer of previous opertions were similr in oth groups (Tle 1). Depending on the # 2001 BJU Interntionl 39

2 40 M. BHANDARI et l. stricture site nd length either longitudinl penile p or circumpenile p were used. All procedures were crried out y one surgeon (M.B.). Ptients were selected for DO or VO t rndom. For the DO, fter midline perinel incision, the strictured prt of the urethr is exposed long with the norml helthy prt of the urethr proximl nd distl to the stricture for < 2.0 cm. The urethr is dissected from the corpor cvernos nd opened longitudinlly on its dorsl spect etween sty sutures (Fig. 1). The urethr is dissected on the ventrl spect of the corpor cvernos well wy from the neurovsculr structures of erection, which rech the corpor cvernos on the dorsomedil side. When the stricture extends into the proximl ul the urethr is dissected meticulously to prevent injury to the neurovsculr structures. When using penile skin, n Tle 1 The demogrphy of the ptients nd outcome fter urethroplsty Vrile Dorsl only Ventrl only P No. of ptients Men (SD): ge (yers) (13) (14.2) 0.46* length (cm) 4.95 (2.2) 5.98 (3.2) 0.24* Site (n) 0.45² Bulr 8 12 Pendulous 10 7 Pnurethrl³ 1 2 Outcome (n) Temporry stule ² Fistul requiring closure ² Flp pseudodiverticulum ² /sccultion Ejcultory dysfunction ² Recurrence ² *t-test; ²Fisher's exct test; ³Involving signi cnt portions of oth pendulous nd ulr urethr. islnd of mesured length is hrvested on drtos pedicle (Fig. 1). When preputil skin is used circumcoronl incision of mesured length nd width is mde nd the inner preputil p developed over the drtos pedicle. The pedicle p is then rought on to the exposed dorsl/ dorsolterlly opened portion of the urethr nd sutured to djoining edges of the urethr using continuous 5/0 polyglctin over 16 F Foley ctheter (Fig. 2). For ulr urethrl stricture repir, the pedicle p is trnsferred into the perineum. If the stricture extends proximlly high in the ulomemrnous urethr, inferior puectomy is undertken to fcilitte exposure of the memrnous urethr (s ws seen in ve of the present ptients). In ptients with ssocited metl stricture (lnitis xerotic oliterns), the dorsl stricturotomy in the pendulous urethr is extended through the glns nd connected to dorsl metotomy, therey voiding extensive suglnulr dissection (c.f. ventrl p plcement; Fig. 3). When using comintion of p nd grft (one ptient), the grft is plced on the dorsl spect of the ulr urethr nd p on the pendulous urethr. A 16 F Foley ctheter is left indwelling in the urethr nd 20 F suprpuic cystostomy plced t the end of the surgery. Colles' fsci is closed with interrupted 4/0 polyglctin sutures. Penile skin is then sutured with the coronl skin using 4/0 polyglctin 910 interrupted sutures. After urethroplsty the ptient is dischrged on urethrl ctheter nd suprpuic cystostomy; VCUG is tken fter 3 weeks. Ptients re given voiding tril if there is no signi cnt extrvstion. If urethrl stul is detected urethrl ctheter dringe is extended for n extr week. Ptients were re-ssessed t 3, 6, 12 nd 18 months with uro owmetry nd urethrl clirtion, with retrogrde urethrogrphy only if recurrence ws suspected. Group differences were clculted using Fisher's exct test or t-test, where pproprite. Fig. 1. Dorsl stricturotomy for pendulous stricture (s) nd circumpenile p (f). Fig. 2. Dorsl only urethroplsty. Flp (f) is supported y the corporl odies (c).

3 DORSAL OR VENTRAL PREPUTIAL/PENILE FLAP FOR URETHRAL STRICTURES 41 Fig. 3., The dorsolterlly lid open pendulous urethr is connected to dorsl metotomy., the penile skin p is tunnelled underneth the glns nd sutured to the dorslly cut mrgins of the metus. Fig. 4. A retrogrde urethrogrm of ptient who underwent ventrl p only shows distl stricture with gint pseudodiverticulum. Results The men (rnge) pek ow rte improved to 24.2 (18±32) ml/s. Four VO ptients nd one DO ptient developed temporry stule, which heled spontneously (Tle 1). One VO ptient with lnitis xerotic oliterns required closure of sucoronl stul. Three ptients in ech group developed mild epiderml skin necrosis, which resolved on conservtive mngement. The medin (rnge) durtion of follow-up ws 27.5 (18±35) months. In six VO ptients p sccultion or pseuodo-diverticulum formtion ws detected nd ll required mnul expression of their postvoid residul urine. In one of these ptients the pseudodiverticulum occurred proximl to distl nstomotic stricture (Fig. 4). In ddition, three VO ptients reported scnty ejcultion nd one hd nejcultion. In the DO group, the rdiogrphic ppernce of the reconstructed urethr ws excellent nd close to tht of norml urethr in ll the ptients (good clire nd smooth trnsition into the urethr t oth ends; Fig. 5). The incidence of recurrent stricture ws not sttisticlly different etween the DO (two, 11%) nd VO (three, 14%) groups. Four of these strictures were mnged successfully with direct visul internl urethrotomy, wheres the fth ptient is witing repet surgery. Discussion When stricture is too long to e excised nd renstomosed, lterntives to single-stge reconstruction include free grfts nd pedicled ps. The chllenge lies in choosing the pproprite technique for prticulr stricture. Flps hve relile vsculr pedicle, wheres Fig. 5., VCUG of ptient with long pendulo-ulr stricture;, retrogrde urethrogrm (t 6 months) of the sme ptient fter dorsl circumpenile only p.

4 42 M. BHANDARI et l. grfts re dependent on the host ed for `tke'. Flps re preferred over grfts in long strictures extending into the pendulous urethr, nd in situtions where multiple opertions with resultnt spongio rosis hve compromised the grft ed [2]. All the present ptients hd recurrent strictures (men length 5.5 cm) nd 78% involved the pendulous urethr, therey mking them more suitle for p reconstruction. Brgli et l. [8] proposed dorsl plcement of the free skin/uccl mucosl grft on the corporl odies nd reported the dvntges of etter mechnicl support, vsculr supply nd decresed incidence of urethrocele formtion. Others [10,11] susequently con rmed this, lthough only with short-term results. A further dvntge reported is the decrese in the incidence of stul formtion, s the suture line is well supported nd protected y the corporl odies nd the urethr [9]. We ttempted to improve on our experience of pedicle p urethroplsty y plcing it dorslly. Although there is no reported comprison of DO nd VO repirs, in our initil experience dorsl plcement ws etter thn ventrl plcement ecuse: (i) the postopertive rdiogrphic studies showed ner norml restortion of the ntomicl ppernce of the urethr; (ii) s the p sits on the roof of the urethr fused with crur there is no sgging, sccultion nd resultnt postvoid drile, s seen in ventrl plcements; (iii) the incidence of postopertive stul is negligile Dorsl plcement of the p is prticulrly dvntgeous in the following situtions. (i) Extension of the p for metl nd glnulr stricture reconstruction; the dorsl stricturotomy on the pendulous urethr cn e esily continued into the glns. Dorsl plcement of the p provided etter cosmetic ppernce, voiding the need to crete glns wings with extensive suglnulr dissection, s needed in the ventrl reconstruction. (ii) When the p hs to extend proximlly up to the ulomemrnous region; in this sitution complete VO would entil dissection of the vsculr ulospongiosus, with signi cnt leeding nd dif cult nstomosis on the ventrl spect of the memrnous urethr. Hence the ventrlly pplied p is usully spirlled t the ulr urethrl region nd then nstomosed on the dorsl spect to the memrnous urethr. Complete dorsl plcement of the p does not require spirlling nd shorter p is required (Fig. 6). Consequently, it is etter ntomiclly plced in this region. Inferior puectomy llows esy ccess to the proximl urethr, s ws seen in ve of the present ptients where the stricture extended to the proximl ul. (iii) In situtions where the p hs to e comined with free grft; it is possile to del with extensive pnurethrl disese, s in one of the present ptients with c Fig. 6. Plcement of ps for strictures in the ulomemrnous region. Dorsl p (-), is shorter nd more ntomiclly plced thn ventrl p (c-). The ventrl p requires dissection of the vsculr ulospongiosus nd spirlling for memrnous urethrl nstomosis. stricture of 14 cm, using comintion of p nd ldder mucosl grft, with excellent results. Here, oth p nd grft were plced dorslly to ridge long defect. This permitted dorsl xtion of the grft with its dvntges of good mechnicl support, etter neovsculriztion nd grft tke. Using this technique, El Ksy et l. [12] reported excellent results in 23 ptients with pn-urethrl strictures. Becuse there is no mechnicl support, ventrl plcement of the p/grft cn led to complictions like urethrl diverticulum formtion [6,7,13] nd sccultion with postvoid driling nd ejcultory filure [14]. In the present VO ptients sgging, sccultion nd pseudodiverticulum formtion were evident on urethrogrms in six ptients, wheres none of the ptients with DO hd this compliction. This cused recurrent UTI in three ptients nd ll six required mnul perinel expression to expel residul urine. McAninch et l. [15] suggested tht creful tiloring of the p to 1.5±2.0 cm wide could void this compliction. In their series of 66 ptients this compliction occurred in only 2% [11]. However Blndy et l. [16]

5 DORSAL OR VENTRAL PREPUTIAL/PENILE FLAP FOR URETHRAL STRICTURES 43 reported `gginess' nd pouch formtion of ventrlly pplied ps in 17 of 114 (15%) ptients. Over- focusing on trimming the p my compromise its vsculrity. A temporry stule occurred in four VO nd one DO ptient, ut most of these heled spontneously on extending ctheter dringe y nother week. The stricture recurred in ve ptients (11%) within medin follow-up of 27.5 months. Most of the recurrences could e mnged y endoscopic techniques nd the recurrence rte ws not signi cntly different etween the groups. However, we ccept tht the follow-up is too short to ssess stricture recurrence nd concede tht complictions of VO ps s seen in the study my e relted to technique. Nevertheless, dorsl plcement of the p seems ntomiclly more logicl; in our hnds the erly outcome of this technique is encourging nd etter thn tht of ventrl p repirs, ut we wit the long-term results. References 1 Wester GD, Wxmn SW. Strictures of the mle urethr. In Gillenwter JY, Gryhck JT, Howrds SS, Duckett JW eds, Adult nd Peditric Urology. 6th edn, Vol. 2, Chpt. 35. St Louis: Mosy, 1996: 1803±36 2 Morey AF, Duckett CP, McAninch JW. Filed nterior urethroplsty: guidelines for reconstruction. J Urol 1997; 158: 1383±7 3 Wessels H, McAninch JW. Current controversies in nterior urethrl stricture repir: free grfts versus pedicled skin- p reconstruction. World J Urol 1998; 16: 175±80 4 Devine PC, Horton CE, Devine CJSr, Devine CJ Jr, Crwford HH, Admson JE. Use of full-thickness skin grfts in repir of urethrl stricture. J Urol 1963; 90: 67±70 5 Presmn D, Green eld DL. Reconstruction of the perinel urethr with free full-thickness skin grft from prepuce. J Urol 1953; 69: 677±9 6 Brigmn JA, Deture FA. Gint urethrl diverticulum fter free full-thickness skin grft urethroplsty. J Urol 1979; 121: Blum JA, Feeney MJ, Howe GE, Steel JF. Skin ptch urethroplsty: 5-yer follow-up. J Urol 1982; 127: Brgli G, Seli C, de Cello V, Mottol A. A one-stge dorsl free grft urethroplsty for ulr urethrl strictures. Br J Urol 1996; 78: 929±32 9 Iselin CE, Wester GD. Dorsl only urethroplsty for urethrl stricture repir. World J Urol 1998; 16: 181±3 10 Mundy AR. The Brgli procedure gives the est results for ptch urethroplsty of the ulr urethr. BJU Int 2000; 85 (Suppl. 5): Pnsodoro V, Emiliozzi P, Gf M, Scrpone P. Buccl mucos urethroplsty for the tretment of ulr urethrl strictures. J Urol 1999; 161: 1501±3 12 El Kssy AEW. Roo ng urethroplsty in the mngement of pn-nterior urethrl stricture disese. J Urol 2000; 163: 71A 13 Crew JP, Nrgund V, Fellows GJ. Symptomtic urethrl hirll nd diverticulum complicting islnd p urethroplsty. Scn J Urol Nephrol 1996; 30: Wester GD, Roertson CN. The vsculrized skin islnd urethroplsty: its role nd results in urethrl stricture mngement. J Urol 1985; 133: 31±4 15 McAninch JW, Morey AF. Penile circulr fsciocutneous skin p in 1-stge reconstruction of complex nterior urethrl stricture. J Urol 1998; 159: 1209±13 16 Rogers HS, McNichols TA, Blndy JP. Long-term results of one-stge scrotl ptch urethroplsty. Br J Urol 1992; 69: 621±8 Authors M. Bhndri, MS, MCh(Urol), FAMS, FNASc, Professor of Eminence of Urology nd Renl Trnsplnttion Director, Snjy Gndhi Post Grdute Institute of Medicl Sciences. D. Duey, MS, FRCS, Senior Resident. B.S. Verm, MS, MCh, DNB, Senior Resident. Correspondence: M. Bhndri, Director, Snjy Post Grdute Institute, Lucknow , Indi. e-mil: mhendr_hndri@us.net Arevitions: DO, dorsl only; VO, ventrl only.