BJUI. One-sided anterior urethroplasty: a new dorsal onlay graft technique

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1 Reconstructive nd Peditric Urology ONE-SIDED ANTERIOR URETHROPLASTY KULKARNI et l. BJUI BJU INTERNATIONAL One-sided nterior urethroplsty: new dorsl only grft technique Snjy Kulkrni, Guido Brgli*, Slvtore Snslone nd Mssimo Lzzeri Centre for Reconstructive Urethrl Surgery, Pune, Indi; *Centre for Reconstructive Urethrl Surgery, Arezzo, Deprtment of Urology, University Tor Vergt, Rome, nd Deprtment of Urology, Snt Chir-Firenze, GIOMI Group, Florence, Itly Accepted for puliction 5 Decemer 2008 Study Type Therpy (cse series) Level of Evidence 4 OBJECTIVE To investigte the fesiility, tolerility, sfety nd efficcy of using new surgicl technique for the repir of nterior urethrl strictures to preserve vsculr supply to the urethr nd its entire musculr nd neurogenic support. PATIENTS AND METHODS In ll, 24 ptients (men ge 46 yers) underwent new one-sided nterior dorsl orl mucosl grft urethroplsty while preserving the lterl vsculr supply to the urethr, the centrl tendon of the perineum, the ulospongiosum muscle nd its perinel innervtion. The cuse of stricture ws instrumenttion in three cses (12%), unknown in five (21%), infection in four (17%), nd lichen sclerosus in 12 (50%). The stricture site ws ulr in 12 cses (50%) nd pnurethrl in 12 (50%). The men stricture length ws 4.2 cm in ptients with ulr strictures nd 10 cm in ptients with pnurethrl strictures. Of 24 ptients, 20 ptients (83%) hd received previous tretments. Clinicl outcome ws considered filure when ny postopertive instrumenttion ws needed, including dilttion. RESULTS The overll men (rnge) follow-up ws 22 (12 55) months. Of the 24 ptients, 22 (92%) hd successful outcome nd two (8%) were filures. One filure ws treted using definitive perinel urethrostomy nd nother filure underwent successful internl urethrotomy. CONCLUSIONS The preservtion of the one-sided vsculr supply to the urethr nd its entire musculr nd neurogenic support should represent slight ut significnt step towrd perfecting the surgicl technique of urethrl reconstruction using minimlly invsive pproch. KEYWORDS urethrl surgery, vsculr spring technique, ulospongiosum muscle, perinel nerve, centrl tendon of the perineum INTRODUCTION In 1880, Duply [1] descried method for urethrl construction in hypospdis tht ws sed on one of the sic principles in urethrl reconstruction, consisting of the formtion of n epithelilized tue from uried strip of skin. In 1949, Denis Browne [2] descried similr method for reconstruction of the urethr in hypospdis. Over time, the Duply s nd Denis Browne s principle, ccording to which the uried strip of intct epithelium ecomes n epithelilized tue, hs een widely used in reconstructive urology. In 1980, Monseur [3] fully pplied Duply s principle nd descried the first dorsl urethroplsty. In 1996, Morey nd McAninch [4] descried the ventrl only grft technique nd, in the sme yer, Brgli et l. [5] descried the dorsl only grft technique. These two new surgicl techniques, suggested minly for repir of ulr urethrl strictures, represent development of the Duply-Denis Browne principle [1,2], showing tht uried, ventrl or dorsl, strip of orl mucos ecomes n epithelilized tue. It ws 116 yers lter tht these uthors confirmed nd expnded on the ingenious Duply principle: ech strip of utologous epithelil tissue hs the potentil of eing used for urethrl regenertion. Recently, new surgicl techniques hve een developed sed on the dorsl only grft urethroplsty first descried y Brgli et l. [5]. In 2000, Kulkrni et l. [6] descried new, full length (penile nd ulr), one-stge orl mucosl grft urethroplsty in ptients with pnurethrl strictures due to lichen sclerosus. In 2001, Asop et l. [7] descried n originl dorsl inly technique. These techniques represent n interesting development of the dorsl grft urethroplsty [5 7]. Recently, Brgli et l. [8] developed muscle nd nerve-spring ulr urethroplsty, to preserve the ulospongiosum muscle nd its perinel innervtions, thus suggesting new minimlly invsive lterntive to trditionl ventrl or dorsl ulr urethroplsty. We comined the use of muscle- nd nervespring ulr urethroplsty from the technique of Brgli et l. [8] with the fulllength dorsl urethrl opening from the technique of Kulkrni et l. [6], nd descried new surgicl technique for the repir of nterior urethrl strictures, so s to preserve the lterl vsculr supply to the urethr, the centrl tendon of the perineum, the ulospongiosum muscle nd its perinel 1150 JOURNAL COMPILATION 2009 BJU INTERNATIONAL 104, doi: /j x x

2 ONE-SIDED ANTERIOR URETHROPLASTY FIG. 1. The preprtion of the ulr urethr strts only on the left side, leving the lterl lood supply to the urethr, the ulospongiosum muscle nd the centrl tendon of perineum intct. culture, residul urine mesurement, uroflowmetry, nd retrogrde nd voiding cystourethrogrphy. The cuse of stricture ws previous urethrl instrumenttion in three cses (12%), unknown in five cses (21%), infection in four cses (17%), nd lichen sclerosus in 12 cses (50%). The stricture site ws ulr in 12 cses (50%) nd pnurethrl (involving oth penile nd ulr trcts) in 12 cses (50%). The men (rnge) stricture length ws 4.2 (3.5 6) cm in ptients with single ulr urethrl involvement nd 10 ( ) cm in ptients with pnurethrl strictures. Of the 24 ptients, 20 ptients (83%) hd received previous tretments: internl urethrotomy, six (25%); dilttion, three (13%); urethroplsty, seven (30%); multiple tretments, four (16%). SURGICAL TECHNIQUE FIG. 2. The urethr is moilized from the lugine only long the left side voiding the full circumferentil dissection of the urethr from the corpor cvernos. The longitudinl incision long the lterl urethrl surfce is underlined. innervtion, nd report the preliminry results in limited series of ptients. PATIENTS AND METHODS From Jnury 2004 to August 2007, 24 ptients (men ge 46 yers, rnge 32 73) underwent one-sided nterior dorsl orl mucosl grft urethroplsty, while preserving the lterl vsculr supply to the urethr, the centrl tendon of the perineum, the ulospongiosum muscle nd its perinel innervtion. Preopertive evlution included clinicl history, physicl exmintion, urine The ptient is plced in simple lithotomy position. The ptient s clves re crefully plced in Allen stirrups with sequentil infltle compression sleeves nd the lower extremities re then suspended y the ptient s feet within the oots of the stirrups. Proper positioning ensures tht there is no pressure on ny spect of the clf muscles nd no inwrd oot rottion, to void perinel nerve injury. The skin of the suprpuic region, scrotum nd perineum is shved nd this region is prepred nd drped ppropritely. The orl mucosl grft is hrvested from the cheek ccording to the stndrd technique. Methylene lue is injected into the urethr to etter define the urethrl mucos. A midline perinel incision is mde. The ulr urethr is dissected from the corpor cvernos only long the left side, strting from the distl trct where muscles re sent (Fig. 1), leving the ulospongiosum muscle nd the centrl tendon of the perineum intct (Fig. 1). Along the right side, the urethr remins ttched to the corpor cvernos for its full length, thus preserving its lterl vsculr lood supply (Fig. 1). On the left side, the urethr is prtilly rotted nd the lterl urethrl surfce is underlined (Fig. 2). The distl extent of the stenosis is identified, the dorsl urethrl surfce is incised long the midline nd the urethrl lumen is exposed (Fig. 3). The stricture is then incised long its entire length y extending the urethrotomy distlly nd proximlly (Fig. 3). Once the entire stricture hs een incised, the length nd width of the remining urethrl plte is mesured. The orl mucosl grft is trimmed to n pproprite JOURNAL COMPILATION 2009 BJU INTERNATIONAL 1151

3 KULKARNI ET AL. size ccording to the length nd width of the urethrotomy, nd it is spred fixed over the tunic lugine (Fig. 4). The two pices of the grft re sutured to the proximl nd distl pices of the urethrotomy. The right mrgin of the orl grft is sutured to the left mrgin of the urethrl mucosl plte (Fig. 4). A Foley 16 F grooved silicone ctheter is inserted (Fig. 5). The ulr urethr, with the intct ulospongiosum muscle, is rotted to its originl position over the grft (Fig. 6). Interrupted 4/0 polyglctin sutures re used to stilize the urethrl mrgins onto the corpor cvernos over the grft on the left side (Fig. 7). At the end of the procedure, the grft is completely covered y the urethr, then y the muscles (Fig. 7). Colles fsci, the perinel ft nd the skin re closed with interrupted sorle sutures. The ctheter is left in situ for 3 weeks. In ptients with pnurethrl strictures, midline perinel incision is mde nd the ulr urethr is dissected, only on the left side, from the corpor cvernos strting from the distl trct where muscles re sent, leving the ulospongiosum muscle nd the centrl tendon of the perineum intct. On the right side, the urethr remins ttched to the corpor cvernos for its full length, thus preserving its lterl vsculr lood supply dissected from the corpor cvernos. By invginting the penis into the perinel incision, the penile urethr is similrly dissected, only long the left side, from the corpor cvernos up to the coronl sulcus (Fig. 8A). On the left side, the urethr is prtilly rotted, the dorsl urethrl surfce is incised long the midline nd the ulr nd penile urethr re opened long the dorsl surfce. A wide metotomy is performed dorslly from the metus through the urethr inside the glns. The first orl mucos grft is sutured to the dorsl edge of the metus nd pushed inside the opened penile urethr nd fixed to the corpor cvernos. Another orl mucos grft is pplied to the corpor cvernos opposite the ulr urethr (Fig. 8B). Continuous upwrd trction is pplied to the inverted penis while pplying the penile portion of the grft to prevent chordee. Quilting sutures re used to spred nd fix the grft to the corpor. The right side of the orl grft is sutured to the left side of the urethrl mucosl plte. A Foley 16 F grooved silicone ctheter is inserted. The full length of the urethr, with the intct ulospongiosum muscle, is rotted to its originl position over the grft. Interrupted FIG. 3. The urethr is longitudinlly opened long its lterl surfce. FIG. 4. The orl mucosl grft is fixed to the underlying lugine nd the right mrgin of the orl grft is sutured to the left mrgin of the urethrl plte. 4/0 polyglctin sutures re used to stilize the urethrl mrgins onto the corpor cvernos over the grft on the left side. At the end of the procedure, the grft is completely covered y the urethr, then y the muscles. Colles fsci, the perinel ft nd the skin re closed with interrupted sorle sutures. The ctheter is left in situ for 3 weeks. The ptient multes on the first postopertive dy nd is dischrged from the hospitl 3 dys fter surgery. All ptients receive rod-spectrum ntiiotics nd re mintined on orl ntiiotics until the ctheter is removed. At 3 weeks fter surgery, the ldder is filled with contrst medium, the Foley ctheter is removed nd voiding cystourethrogrphy is otined JOURNAL COMPILATION 2009 BJU INTERNATIONAL

4 ONE-SIDED ANTERIOR URETHROPLASTY FIG. 5. Foley 16 F silicone grooved ctheter is inserted. stricture ws previous urethrl instrumenttion. The ptient developed complete stricture recurrence requiring suprpuic tue for cute urinry retention 8 months fter surgery nd definitive perinel urethrostomy ws mde. Another filure ws in s ptient (41-yers-old) with pnurethrl stricture (13 cm) due to lichen sclerosus. The ptient developed nonolitertive firous ring t the proximl nstomosis nd n internl urethrotomy ws mde, with successful outcome t the preliminry short follow-up. DISCUSSION FIG. 6. The urethr is rotted to its originl position thus covering the orl grft. In the originl dorsl only techniques the urethr is circumferentilly moilized form the corpor cvernos to etter expose its dorsl surfce nd to spred fix the grft over the underlying lugine [5,6]. In 2008, Brgli et l. [8] showed tht the dorsl urethrl surfce could e esily pproched leving the ulospongiosum muscle nd the centrl tendon of the perineum intct, thus lso preserving the rnches of the perinel nerves from surgicl injury. RESULTS The overll men (rnge) follow-up ws 22 (12 55) months. Clinicl outcome ws considered filure when ny postopertive instrumenttion ws needed, including dilttion. In ll ptients, postopertive voiding cystourethrogrphy ws performed 3 weeks fter surgery. Uroflowmetry nd urine culture were repeted every 4 months in the first yer nd nnully therefter. When symptoms of decresed force of strem were present nd uroflowmetry ws less thn 14 ml/s, urethrogrphy, urethrl ultrsound nd urethroscophy were performed. Of the 24 ptients, 22 (92%) hd successful outcome nd two (8%) were filures. One filure ws in ptient (73-yers-old) with ulr urethrl stricture (5.5 cm) recurring following prior orl grft ventrl urethroplsty. The cuse of the primry The ulospongiosum muscle is primrily responsile for ejcultion ecuse rhythmic contrctions of this muscle nd other perinel muscles expel semen from the urethr nd proly hve n importnt role in expelling urine, voiding urine sequestrtion in the lrge urethrl ul fter micturition [8]. Yng nd Brdley [9] illustrted the role of the perinel nerve in ulospongiosum muscle contrctions nd suggested tht ejcultory disorders might result from disruption of one or more of the reflex pthwys providing innervtion of the ulospongiosum muscle. These disorders my mnifest s decresed force of semen expulsion nd low semen volume cused y inefficient ulospongiosum contrctility [9]. Yucel nd Bskin [10] showed tht perinel nerves innervte the ulospongiosum muscle nd send out fine rnches tht penetrte the corpus spongiosum, minly in the ulr re. The perinel nerves my e injured during ulr urethroplsty performed ccording to the stndrd procedures [8]. During dissection of the centrl tendon of the perineum, the perinel nerves re most likely to e dmged upon emergence from the ischiorectl foss, or when the ulospongiosum muscle is fully divided long the midline, the fine rnches of the perinel nerves penetrting into the JOURNAL COMPILATION 2009 BJU INTERNATIONAL 1153

5 KULKARNI ET AL. corpus spongiosum my e dmged [8]. Moreover, the perinel nerve rnches my e dmged y incorrect or excessive use of cutery [8]. For these resons, ulr urethroplsty should e performed using conservtive pproch [8]. FIG. 7. At the end of the procedure, the urethr is fixed on the left side, leving the lterl lood supply to the urethr, the ulospongiosum muscle nd the centrl tendon of perineum intct on the opposite side. Circumferentil moiliztion of the urethr, s suggested in the originl dorsl only grft technique [5,6], severs the vsculr connections etween the corpus spongiousum nd the tunic lugine, nd the lterl vsculr connection etween the urethr nd the superficil perinel tissue on oth sides. This vsculr supply to the urethr my e compromised in ptients who hd undergone prior filed urethroplsty or in ptients with full-length nterior urethrl strictures due to extensive spongiofirosis. We relize tht in performing dorsl plcement of the grft in the lugine, the full circumferentil dissection of the urethr is unnecessry nd my compromise the residul lood supply to the urethr. FIG. 8. A, By invginting the penis into the perinel incision, the penile urethr is dissected only long the left side, from the corpor cvernos up to the coronl sulcus. B, The first orl mucos grft is sutured to the dorsl edge of the metus nd pushed inside the opened penile urethr nd fixed to the corpor cvernos. Another orl mucos grft is pplied to the corpor cvernos opposite the ulr urethr. Initilly (2004), we selected this new onesided nterior urethroplsty for ptients with prior filed urethroplsty (six cses) or in ptients with full-length nterior urethrl strictures (12 cses) nd, susequently, we lso extended the use of this technique to ptients with long ulr urethrl strictures who hd not undergone prior urethroplsty (six cses). In our previous experience, onestge ulr urethroplsties using stndrd procedures showed n 83.5% success rte nd the dorsl orl mucosl grft urethroplsty showed 77.3% success rte [11]. In the present preliminry series of ptients using new vsculr, muscle nd nerve-spring procedure, the success rte ws 92%. The fctors currently reported s influencing the success rte of ny kind of urethroplsty re: ptient ge, cuse of stricture, length nd previous tretments [11,12]. Our reports hve shown tht these fctor hve no effect on the success rte, suggesting tht other fctors (possily vsculr nd neurogenic urethrl injury) my ply n importnt role in determining stricture recurrence [11,12]. The preservtion of the one-sided vsculr supply to the urethr nd its entire musculr nd neurogenic support represents slight ut significnt step towrd perfecting the surgicl technique of urethrl reconstruction, using minimlly invsive pproch. In 2006, Elthwy et l. [13] descried new vesselspring excision nd primry nstomosis of the urethr, preserving the rteries of the ul. Further studies on lrge series of ptients re necessry to confirm tht preservtion of the one-sided lterl vsculr supply to the urethr nd its entire musculr nd neurogenic support reduces the incidence of stricture recurrence nd postopertive complictions [8]. Dt collection is ongoing JOURNAL COMPILATION 2009 BJU INTERNATIONAL

6 ONE-SIDED ANTERIOR URETHROPLASTY CONFLICT OF INTEREST None declred. REFERENCES 1 Duply S. Sur le tritment chirurgicl de l hypospdis et de l epispdis. Arch Gen Med 1880; 145: Browne D. An opertion for hypospdis. Proc R Soc Med 1949; 42: Monseur J. [Widening of the urethr using the supr-urethrl lyer]. J Urol (Pris) 1980; 86: Morey AF, McAninch JW. When nd how to use uccl mucosl grfts in dult ulr urethroplsty. Urology 1996; 48: Brgli G, Selli C, Tosto A, Plminteri E. Dorsl free grft urethroplsty. J Urol 1996; 155: Kulkrni SB, Kulkrni JS, Kirpekr DV. A new technique of urethroplsty for lnitis xerotic oliterns. J Urol 2000; 163 (Suppl.): 352 (strct V31) 7 Asop HS, Grg M, Singhl GG, Singh L, Asop J, Nischl A. Dorsl free grft urethroplsty for urethrl stricture y ventrl sgittl urethrotomy pproch. Urology 2001; 58: Brgli G, De Stefni S, Annino F, De Crne C, Binchi G. Muscle- nd nerve-spring ulr urethroplsty: new technique. Eur Urol 2008; 54: Yng CC, Brdley WE. Somtic innervtion of the humn ulocvernous muscle. Clin Neurophysiol 1999; 110: Yucel S, Bskin LS. Neurontomy of the mle urethr nd perineum. BJU Int 2003; 92: Brgli G, Guzzoni G, Lzzeri M. Onestge ulr urethroplsty: retrospective nlysis of the results in 375 ptients. Eur Urol 2008; 53: Brgli G, De Angelis M, Romno G, Lzzeri M. Long-term followup of ulr end-to-end nstomosis: retrospective nlysis of 153 ptients in single center experience. J Urol 2007; 178: Elthhwy EA, Virsoro R, Jordn GH. Vessel spring excision nd primry nstomosis of the urethr. J Urol 2006; 175 (Suppl.): 104 (strct 315) Correspondence: Mssimo Lzzeri, Deprtment of Urology, Snt Chir Hospitl, P.zz Indipendenz 11, Florence, Itly. e-mil: lzzeri.m@tiscli.it JOURNAL COMPILATION 2009 BJU INTERNATIONAL 1155