european urology 51 (2007)

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1 european urology 51 (2007) available at journal homepage: Reconstructive Urology Staged Pendulous-Prostatic Anastomotic Urethroplasty Followed By Reconstruction of the Anterior Urethra: An Effective Treatment for Long-Segment Bulbar and Membranous Urethral Stricture Deng-Long Wu, San-Bao Jin, Juan Zhang, Yong Chen, Chong-Rui Jin, Yue-Min Xu * Department of Urology, Affiliated Sixth People s Hospital, Shanghai Jiaotong University, Shanghai, China Article info Article history: Accepted July 6, 2006 Published online ahead of print on July 24, 2006 Keywords: Posterior urethra Urethral stricture Complex Anastomosis Urethroplasty Abstract Objectives: To describe a novel surgical technique for male long-segment urethral stricture after pelvic trauma using the intact and pedicled pendulous urethra to replace the bulbar and membranous urethra, followed by reconstruction of the anterior urethra. Methods: Two patients with long-segment post-traumatic bulbar and membranous urethral strictures with short left pendulous urethras who had undergone several failed previous surgeries were treated with staged pendulousprostatic anastomotic urethroplasty followed by reconstruction of the anterior urethra. This procedure was divided into three stages. First-stage surgery was mobilization of the anterior urethra down to the coronary sulcus and then rerouted to the prostatic urethra followed by pendulous-prostatic anastomotic urethroplasty with transposition of the penis to the perineum. Second-stage surgery was transecting the anterior urethra at the revascularised coronary sulcus 6 mo later, followed by straightening of the penis and urethroperineostomy. Third-stage surgery was reconstruction of the anterior urethra 6 mo later. Results: Postoperatively, the two patients reported satisfactory voiding. For patient 1, retrograde urethrography showed that the urethra was patent, and that the mean maximal flow rate (MFR) was 18.4 ml/s with no postvoiding residual urine after the third-stage surgery and at 3-yr follow-up. For patient 2, a 22F urethral catheter could pass smoothly through the urethra, and the MFR was 19.5 ml/s with no postvoiding residual urine at 2-yr follow-up. Conclusions: This procedure was an effective surgical option for men with complex long-segment post-traumatic bulbar and membranous urethral strictures, especially for those who had undergone failed previous surgical treatments. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, Affiliated Sixth People s Hospital, Shanghai Jiaotong University, Shanghai , China. Tel ; Fax: address: xuyuemin@263.net (Y.-M. Xu) /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 european urology 51 (2007) Introduction Surgical repair of post-traumatic posterior urethral strictures remains one of the most challenging problems in urology, especially for those patients with complex posterior urethral strictures who have undergone failed previous surgical treatments [1]. We designed a novel staged procedure for those with long-segment post-traumatic posterior urethral distraction defects and short left pendulous urethra, treated two patients, and obtained good outcomes. 2. Methods 2.1. Clinical materials Patient 1 A 23-year-old male presented with an 11-yr history of a posttraumatic posterior urethral distraction defect, accompanied by a posterior urethrorectal fistula. Prior to admission, the patient had undergone 12 failed previous treatments, including 3 transperineal anastomotic urethroplasties, 4 endoscopic internal urethrotomies, 3 cystolithotomies, and 2 perineal abscess incisions and drainages. Voiding urethrography (VUG) through the previously placed suprapubic tube, combined with retrograde urethrography (RUG) and urethral ultrasound, showed that the length of the occluded urethra from membranous to bulbar was 6.5 cm, the length of the normal prostatic urethra was about 2.5 cm, and the length of the normal anterior urethra was about 6 cm (Fig. 1A and B). The disorder was accompanied by penile retraction, posterior urethrorectal fistula, bladder stones, urinary tract infection, bilateral vesicoureteral reflux, and erectile dysfunction Patient 2 A 20-year-old male presented with a 2-yr history of posttraumatic posterior urethral rupture. Two years before admission, the patient was treated with suprapubic cystostomy as an emergency treatment, after which he underwent two failed transperineal anastomotic urethroplasties. A RUG combined with a VUG revealed that the length of the residual pendulous urethra was 6 cm, the prostatic urethra was 2.5 cm, and the occlusive urethra was 10 cm Surgical procedures This procedure was divided into three stages First stage The first-stage surgery was a pendulous-prostatic end-to-end anastomotic urethroplasty with transposition of the penis to the perineum. With the patient in the exaggerated lithotomy position, an inverted Y-shaped perineal incision was made, extending anteriorly to the scrotum and penis. After the scrotum was split open, the anterior urethra was mobilized circumferentially down to the coronary sulcus (Figs. 2A and 3A). The obliterated urethra and periurethral fibrotic tissues were completely excised until a healthy prostatic urethra was mobilized about 0.5 cm for the suture. At the same time, a crural bifurcation of the corporeal body separation was made. The penis and external urethral meatus were transposed to the perineum through the scrotal septum incision. The pendulous urethra was rerouted to the prostatic urethra. Tension-free pendulous-prostatic anastomotic urethroplasty was performed with the use of 4-0 polyglycolic acid sutures (Figs. 2B and 3B). For patient 1, a tension-free anastomosis could not be achieved through the perineal route; therefore, a transpubic incision and pubectomy were made (Fig. 3A). A 16F Foley catheter was used as a urethral stent, a suprapubic cystostomy tube was inserted, and the perineal wound was closed with a drain. Antibiotics were administered 3 d preoperatively, intraoperatively, and for 10 d postoperatively according to the results of the urine culture. Estradiol benzoate was used for at least 1 wk. Fig. 1 A: Hypogastrium and perineal scar for case 1; B: RUG and VUG show anterior and posterior urethra and bilateral vesico-ureteral reflex for case 1 ( : anterior urethra, : sound).

3 506 european urology 51 (2007) penis and the scrotum between the urethral defects were sutured to two sides of the penile albuginea. This ventral part of the penile albuginea from the urethroperineostomy to the coronary sulcus formed an open urethral ditch that would later become epithelized (Figs. 2C and 5). A 16F Foley catheter was used for drainage of urine and removed 1 wk postoperatively. The patient voided by squatting, and the urethral ditch was left open. After the second-stage operation, the urethra was something like an artificial hypospadia with a normal urethral meatus. Fig. 2 Diagram for operation. A: Long-segment urethral stricture pre-operation ( : long-segment urethral stricture); B: The first-stage operation ( : anterior urethra); C: The second-stage operation ( : urethroperineostomy); D: The urethra after the third-stage operation ( : new anterior urethra). The stenting catheter was removed 14 d postoperatively. Uroflowmetry and VUG combined with RUG were done by way of the suprapubic catheter several days later. If voiding was satisfactory, the suprapubic catheter was removed 1 day later. The patients voided by squatting (Fig. 4) Second stage The second-stage surgery included straightening of the penis and a urethroperineostomy. This operation was performed at least 6 mo later when the anterior urethra was revascularized from periurethral tissue. With the patient in the lithotomy position, an incision of the perineum and the lateral sides of the penis was made. The curved spongy body of the penis was separated. After the urethra was transected at the site of the coronary sulcus, the spongy body was straightened. Urethroperineostomy was performed with the proximal urethral meatus being fractionated into three valves and sutured with perineal skin. The fibrotic tissue of the albuginea penis was excised. The distal urethral stump was sutured with the skin of the penis. Skin edges of the Third stage The third-stage surgery was reconstruction of a new anterior urethra using second-stage Johanson urethroplasty. It was performed 6 mo after the second surgery. With the patient in the supine position, a silicon tube with multiple holes was passed through the penile urethra into the bladder as a stent. A longitudinal incision of two sides of the ventral epithelized skin was made, which circled the proximal and distal meatus of the urethra, and extended deep to the albuginea penis. A cm wide strip of ventral epithelized skin at the urethral ditch was used to form the dorsal wall of the new urethra. The lateral skin was undermined and closed over the buried strip to form a tube for the new urethra. In the meantime, a release incision on the dorsum of the penis was made to ease the tension of the ventral wound (Fig. 2D). The ventral side of the new urethra was left to become epithelialized. A suprapubic cystostomy tube was placed. The urethral stent was removed 14 d postoperatively. If voiding was satisfactory, the suprapubic catheter was then removed 1 day later Treatment of urethrorectal fistula If the patient had a urethrorectal fistula, it was excised and neoplastied simultaneously during the operation. Well-vascularized tissue such as the bulbocavernous muscle and surrounding tissues were inserted into the gap between the rectum and urethra to prevent fistula recurrence Interval follow-up Patients were followed up by an assessment of symptoms and urinary flow rate, and an ultrasound determination of the postvoid residual urine volume at 3 and 6 mo, and annually thereafter. 3. Results Three months after the cystolithotomy, patient 1 underwent the first-stage procedure by the transperineal and transpubic route (Fig. 3A). Simultaneously the urethrorectal fistula was excised by means of neoplasty. The second-stage surgery was performed 1 yr later, and the third-stage surgery 1 yr after the second-stage. After all three stage surgeries, a radiourethrography showed that the urethra was patent and that the bilateral vesicoureteral reflux had almost disappeared (Fig. 6A). The

4 european urology 51 (2007) Fig. 3 Process of first staging operation for case 1. A: Mobilization of anterior urethra to coronary sulcus ( : anterior urethra); B: Transposition of penis to perineum and pendulous-prostatic anastomostic urethroplasty ( : pendulousprostatic anastomosis). patient voided satisfactorily (Fig. 6B), and maximal flow rate (MFR) was 18.8 ml/s, 18 ml/s, and 18.3 ml/s with no postvoiding residual urine after the thirdstage operation and at 2-yr and 3-yr follow-up, respectively. The patient had moderate erectile dysfunction but was able to have vaginal intercourse accompanied with retrograde ejaculation and had mild stress incontinence when the bladder was full (requiring one pad per day). Fig. 4 Voiding by squatting after the first-stage operation. Fig. 5 Straightened penis and urethroperineostomy and urethral ditch after the second-stage operation for case 1 ( : urethral ditch, : urethroperineostomy).

5 508 european urology 51 (2007) Fig. 6 A: RUG and VUG show patent urethra after the third stage operation for case 1; B: Urination after the third stage operation. For patient 2, the first-stage surgery was performed through a perineal incision. The secondstage surgery was done 6 mo later, and the third stage was performed 8 mo after that. The patient voided satisfactorily after all procedures. The 22F urethral sound could pass smoothly through the urethra, and the MFR was 19.5 ml/s with no postvoid residual urine at 2-yr follow-up. 4. Discussion Traumatic injury to the prostatomembranous urethra has been reported to occur in about 10% of patients with pelvic fractures [2]. No single procedure is curative for all urethral strictures. Surgical options for urethral strictures are based primarily on the location and length of the stricture. The techniques used include excision with primary anastomosis, onlay repairs, stricture excision with augmented anastomosis, a tubularised flap of sigmoid colon, and so on [1,3 6]. Posterior urethroplasty generally is more difficult, but anterior urethroplasty is relatively easier, and end-to-end anastomotic urethroplasty has a better success rate (68 96%) for posterior urethral strictures [3]. We usually prefer one-stage repair over two-stage repair, but for patients with very long and complex posterior urethral strictures, especially those who have had repeated failed urethral surgeries, the treatment is difficult and controversial. In our group, the urethral distraction defect was very long, there was not enough healthy skin graft, and the graft bed was poor because of the previous failed surgeries, so substitution urethroplasty was not feasible. It was also difficult to perform routine anastomotic urethroplasty because of the high tension between the urethral stumps. So we sufficiently used the short intact and pedicled pendulous urethra to substitute for the bulbar and posterior urethra, and a tension-free pendulousprostatic anastomotic urethroplasty was acquired by temporary transposition of the penis to the perineum to shorten the defect distance between the urethral stumps. At least 6 mo later when the anterior urethra was revascularised from periurethral tissue, it was transected at the coronary sulcus, and the penis was straightened. Finally, a new anterior urethroplasty was performed by means of a Johanson urethroplasty. The anterior urethra with its corpus spongiosum and abundant blood supply can survive when good supporting tissues are absent in the surrounding area after a pubectomy and when a restenosis is not formed. At the same time, reconstruction of the long anterior urethra is relatively easy using the Johanson urethroplasty. Patient 1 experienced 12 unsuccessful previous procedures and was severely scarred in the perineal and lower abdominal zone. After treatment with this staged operation, satisfactory voiding was achieved, and the bilateral vesicoureteral reflux nearly disappeared. There was no restenosis and the MFR was 18.3 ml/s at 3- yr follow-up. Patient 2 had undergone two previous failed urethroplasties but also achieved satisfactory voiding after the staged operation. His MFR was 19.5 ml/s at 2-yr follow-up. The success of the first-stage anastomotic procedure depends on mobilization of the two ends of the urethra, careful and complete excision of

6 european urology 51 (2007) periurethral scar tissues and the strictured urethra, spatulation of the proximal and distal urethral ends, and a tension-free, end-to-end, mucosa-to-mucosa anastomosis between the two healthy ends [3,4,7 9]. When the distraction defect is longer than 3 cm, urethral mobilization alone, which can shorten the defect by 2 3 cm, is not sufficient to achieve a tension-free anastomosis. In such cases, the mobilized anterior urethra has to take a shorter and more direct route to reach the prostatic urethra. This procedure includes corporeal body separation, which shortens the distance by 1 2 cm, inferior pubectomy, which shortens the defect by 1 2 cm, and rerouting the urethra through the corporeal body, which also shortens the distance by 1 2 cm [9 11]. In our series, the two patients had long-segment urethral defects and left shorter anterior urethras. The methods described above were not enough for tension-free anastomosis; therefore, we transposed the penis to the perineum to shorten the gap between urethral stumps, and then rerouted the pendulous urethra through the gap between the two spongy bodies of the penis to the prostatic urethra. The tension-free pendulous-prostatic anastomotic urethroplasty then was easily performed. Transposition of the penis and the urethral meatus to the perineum can shorten the defect by at least 6 cm, which is the key of this staged procedure. A successful outcome is also dependent on retrograde blood flow from the dorsal arteries of the glans penis. Normally, the main blood supply of the pendulous urethra and bulbar spongy tissue is derived from the posterior bulbar arteries, which may be injured when there is a posterior urethral rupture and must be transected after anastomotic urethroplasty. The retrograde blood supply derived from the glans is sufficient for the mobilized pendulous urethra, but attention must be paid to preserve the blood supply from the glans penis and to ensure that mobilization of the urethra never surpasses the coronary sulcus; otherwise ischemic necrosis of the anterior urethra may occur. Another key to achieving long-term results with this technique is the complete excision of the periurethral scar tissues [10,12 14]. We palpated the urethra and periurethral tissues during the operation; firm tissues suggested that the scarred tissue was incompletely excised. We always excised the scar tissue until the surrounding tissue was diffusely soft. Infection is one cause for a failed urethroplasty [1]. Patients with preoperative urinary tract infection had twice as many failures (28.6%) as those with sterile urine (14.5%) [1]. Preventionand elimination of preoperative, intraoperative, and postoperative infection is one of the key steps of a successful urethroplasty. The bladder and urethral stump should be washed with iodophors and saline. The suprapubic tube should be replaced before the operation. Drainage should be sufficient, and the perineal wound should be pressure dressed postoperatively. There are many methods for anterior urethroplasty, such as scrotal inlay urethroplasty, buccal mucosal urethroplasty [15,16], colonic mucosal urethroplasty [6], pedicled penile skin flap [16], and circular fasciocutaneous penile flap [17,18]. The staged old Johanson urethroplasty is a good treatment for the difficult and complicated urethral strictures for which a high success rate was achieved. The two patients in our study had obvious scar tissue, insufficient healthy skin grafts, and a bad graft bed. The methods described above were not suitable for these patients, so the staged Johanson procedure was chosen for the anterior urethroplasty. Before the operation, the patients were informed that the penis would be cosmetically distorted, that they would not be able to have normal sexual intercourse and would have to void by squatting for at least 6 mo after the first stage surgery, and that the entire treatment would last a long time. Having experienced many failures with other procedures before, all patients accepted this type of treatment, simply because the most imminent demand for them was to void through the urethra. During and after these procedures, all of these patients are living fairly satisfactory lives and are psychologically stable. 5. Conclusions Our result showed that this staged procedure is effective for patients with a complex posterior and bulbar anterior urethral distraction defect who have at least 5 6 cm of normal pendulous urethra and have a normal prostatic urethra, especially for those who had undergone previous failed surgeries. This procedure has a higher success rate because of the tension-free anastomotic urethroplasty. The disadvantage for this staged procedure is the prolonged hospitalization. Longer follow-up and more cases are needed to further evaluate the continued use of this technique. Acknowledgements We gratefully acknowledge the manuscript revision by Professor Pamela Unger from Mount Sinai Medical Center, New York, NY, USA.

7 510 european urology 51 (2007) References [1] Roehrborn CG, McConnell JD. Analysis of factors contributing to success or failure of one stage urethroplasty for urethral stricture disease. J Urol 1994;151: [2] Glass RE, Flynn JT, King JB, Blandy JP. Urethral injury and fractured pelvis. Br J Urol 1978;50: [3] Pansadoro V, Emiliozzi P. Which urethroplasty for which results? Curr Opin Urol 2002;12: [4] Ennemoser O, Colleselli K, Reissigl A, Poisel S, Janetschek G, Bartsch G. Post-traumatic posterior urethral stricture repair: anatomy, surgical approach and long-term results. J Urol 1997;157: [5] Lee YT, Cho TW, Jeong HS, Lee YK, Hong YK. Reconfigured sigmoid colon neourethra: substitution of refractory posterior urethral stricture. Urology 2005;65: [6] Xu YM, Qiao Y, Sa YL, et al. 1-stage urethral reconstruction using colonic mucosa graft for the treatment of a long complex urethral stricture. J Urol 2004;171: [7] Koraitim MM. The lessons of 145 post-traumatic posterior urethral stricture treated in 17 years. J Urol 1995;153:63 6. [8] Mundy AR. Urethroplasty for posterior urethral strictures. Br J Urol 1996;78: [9] Koraitim MM. Failed posterior urethroplasty: lessons learned. Urology 2003;62: [10] Webster GD, Ramon J, Kreder KJ. Salvage posterior urethroplasty after failed initial repair of pelvic fracture membranous urethral defects. J Urol 1990;144: [11] Peterson AC, Webster GD. Management of urethral stricture disease: developing options for surgical intervention. Br J Urol 2004;94: [12] Turner-Warwick R, Chapple C. Urethral strictures. In: Cohen MS, Resnick MI, editors. Reoperative urology. Boston: Little, Brown; p [13] Corriere JN. 1-stage delayed bulboprostatic anastomotic repair of posterior urethral rupture: 60 patients with 1-year followup. J Urol 2001;165: [14] Koraitim MM. Post-traumatic posterior urethral strictures: Preoperative decision making. Urology 2004;64: [15] Burger RA, Muller SC, El-Damanhoury H, Tschakaloff A, Riedmiller H, Hohenfellner R. The buccal mucosa graft for urethral reconstruction: a preliminary report. J Urol 1992;147: [16] El-Kasaby AW, Fath-Alla M, Noweir AM, El-Halaby MR, Zakaria W, El-Beialy MH. The use of buccal mucosa patch graft in the management of anterior urethral strictures. J Urol 1993;149: [17] Devine PC, Horton CE, Devine CJ, Devine Jr CJ, Crawford HH, Adamson JE. Use of full thickness skin grafts in repair of urethral strictures. J Urol 1963;90: [18] Carney KJ, McAninch JW. Penile circular fasciocutaneous flaps to reconstruct complex anterior urethral strictures. Urol Clin North Am 2002;29: Editorial Comment Enzo Palminteri enzo.palminteri@inwind.it Complex posterior urethral strictures represent a reconstructive challenge especially after previously failed urethroplasties. The new stricture may be longer, involving the bulbar tract stretched during the past bulboprostatic anastomosis, and the surgical solutions are limited by poor tissue conditions compromised by wide scars. In these situations the corporeal body separation, inferior pubectomy, and urethral rerouting are not enough to guarantee a tension-free, new end-toend anastomosis [1]. Buccal mucosa (BM) does not take on scarred tissues. Transferring a foreskin pedicled tube to the prostatic apex creates excessive tension on the peduncle [2]. Tubularised colon flap is an unsuccessful technique. Reconstructive surgeons know the necessity of staged surgeries in complicated strictures and the Schreiter mesh graft seems a suitable solution [3]. Otherwise a definitive perineal urethrostomy is not the advisable choice in case of posttraumatic incontinence. In this paper the authors propose a three-staged technique. The first stage allows the replacement of a long posterior urethral gap using the penile urethra as a tubed flap for the pendulous-prostatic anastomosis. At the second stage, the penile urethra is transected at the coronary sulcus and the penis is restraightened. At the third stage, the anterior urethral reconstruction is performed using the Johanson procedure and the revascularised penile urethra previously transposed into the perineum. After transection at the sulcus, doubt remains about the possibility of revascularisation of the penile urethral stump by means of the penile-prostatic anastomosis by the uncertain bulbar arteries or periurethral tissues [4]. For the anterior reconstruction, one possibility may be to graft the distal urethral ditch obtained at the second stage with BM or other tissues to make a new urethral plate to be tubularised at the third stage. The technique is cosmetically distorting after the first stage, but motivated patients easily accept a complex staged strategy to improve their voiding situation. Finally, the article adds to the discussion on the treatment of these difficult and repeatedly failed cases. References [1] Webster GD, Ramon J, Kreder KJ. Salvage posterior urethroplasty after failed initial repair of pelvic frac-

8 european urology 51 (2007) ture membranous urethral defects. J Urol 1990;144: [2] Carney KJ, McAninch JW. Penile circular fasciocutaneous flaps to reconstruct complex anterior urethral strictures. Urol Clin North Am 2002;29: [3] Schreiter F, Noll F. Mesh graft urethroplasty using skin graft or foreskin. J Urol 1989;142: [4] Turner-Warwick R, Chapple C. Urethral strictures. In: Cohen MS, Resnick MI, editors. Reoperative urology. Boston: Little, Brown; p