Brifhh Journal of Urology (1!378), 50, 410-414
One-stage Excision Urethroplasty for Stricture A. PANAGAKIS, J. C. SMITH and J. L. WILLIAMS Departments of Urology, Churchill Hospital, Oxford, and Hallamshire Hospital, She ffield
Summary- Forty-two patients have had a one-stage excision urethroplasty for localised strictures in the bulbous urethra. The stricture recurred in 2 patients, one requiring a scrota1 flap urethroplasty and the other a further excision and repair with a good result. With careful selection this operation gives very good results and has been used successfully in the primary repair of complete rupture of the bulbous urethra.
Excision of urethral strictures and primary repair by end-to-end anastomosis were described in the early nineteenth century but the results were unsatisfactory. Heusner (1883) carried out excision and suture and Guyon (1892) excised the stricture incompletely, leaving an intact strip on the posterior urethral wall. Rochet (1 899) advocated urinary diversion and claimed increased success. Russell (1915) excised the stricture and only partially repaired the urethra. He established the principle of the buried strip which was later successfully applied by Browne (1 949) to hypospadias repair, and by Johannson (1953) to the problem of urethral stricture. Marion (1912) used a midline perineal approach for stricture and acute trauma of the bulb. He excised the diseased or damaged tissue and repaired the urethra by direct end -to-end anastomosis. At present, one-stage excision and repair are not popular and Blandy (1976) stated that only 1 in his series of 210 urethroplasties was treated by this method. Eight had been treated by one-stage excision and repair elsewhere and all of these required revision. In contrast with the depressing results which have generally been recorded, ours have been encouraging. Patients Forty-two patients aged from 20 t o 50 years were reviewed. The stricture was bulbar in 41 and penile in 1 patient. One patient had 2 strictures that were 5 cm apart. Received 16 March 1978. Accepted for publication 8 June 1978.
The usual criteria for the failure of conservative management were applied. The one-stage excision and repair were strictly reserved for cases of noninflammatory origin not suitable for internal urethrotomy and in which scarring and damage to the mucosal lining were localised to a short segment. The stricture was usually single and was distal to the external sphincter. A detailed history and a urethrogram of good quality enabled the surgeon to determine whether a case was suitable, but the final decision was made when the stricture had been exposed; if the scarring and diseased mucosa extended for more than 1 cm either side of the stricture, excision of the stricture was not performed. The aetiology was trauma in 17 patients, inflammation in 6, following transurethral resection in 8 and after catheterisation in 2. Three patients were thought to have congenital strictures and in 6 the cause was not known. Operative Technique
Principles Not only must the stricture be excised, but all gross peri-urethral scar must be removed; otherwise a recurrence will probably occur. The cut ends of the urethra, which is divided completely, must reveal healthy mucosa and a normal calibre urethra. It is essential to mobilise the distal urethra so that a tension-free anastomosis can be fashioned and first intention healing ensured. In order to avoid a circumferential scar (which may lead to a recurrence), a zig-zag (Sheffield) or oblique (Oxford) suture line is designed. As the repair cannot be fully water-tight the urine is diverted so that fistula formation and excessive peri-urethral scarring will be avoided. In the
410
41 1
ONE-STAGE EXCISION URETHROPLASTY FOR STRICTURE
Fig. 1 Exposureoftheurethrashowingreflection of the bulbo-spongiosus muscle.
Fig. 2 The stricture opened.
Oxford series a suprapubic cystotomy was used, but in Sheffield an indwelling catheter was relied upon. In both centres 3/0 Dexon was used for suturing. The Operation Under general anaesthesia, with the patient in the exaggerated lithotomy position, a metal sound of large calibre is passed as far as the stricture. A midline perineal incision 4 to 5 cm long is made with the stricture site (as determined by the position of the tip of the sound and the urethrogram) in the centre. The bulbo-spongiosus muscle is divided in the midline, freed from the sheath of the corpus spongiosum which invests the urethra, and held in the blades of a Turner-Warwick selfretaining retractor (Fig. 1). The urethra with its surrounding corpus spongiosum is freed above and below the stricture from the underlying sheath of the corpus cavernosum for a distance of 3 to 4 cm distally and 1 to 2 cm proximally. Only when this has been accomplished and haemostasis secured is the urethra opened in the midline by cutting on to the sound just distal to the stricture for a distance of about 1 cm. Stay sutures are inserted to reveal the urethral lumen
Fig. 3 After excision of the stricture.
and the face of the stricture (Fig. 2). A probe is passed through the stricture and the incision is continued in the midline, dividing the stricture and entering the urethra proximal to the stricture. If the channel is lost in the scar tissue, the careful application of suprapubic pressure may be followed by the escape of urine from the proximal end of the strictured urethra which acts as a guide. Only rarely is it necessary t o have to pass a sound from the bladder into the posterior urethra so that it can be located. It is important to examine the lining mucosa to be certain that the urethra and not a false passage is being followed. The latter has a reddish coloured lining and the passage of an instrument along it is resisted through its whole length. Having opened the proximal urethra it should now be possible to pass a wide-bore sound with ease. If the stricture is localised and the urethra on either side appears healthy the stricture is excised, leaving a gap which should not exceed 2 cm (Fig. 3). If necessary it is now easy to free the distal urethra further by dividing its attachments to the sheath of the corpus cavernosum in the midline. Each cut end of the urethra is cut obliquely or incised in 2 places opposite to each other to
412
BRITISH JOURNAL OF UROLOGY
carried out. Tension on the suture line can be relaxed by suturing the distal urethra to the corpus cavernosum sheath. The repair is covered by re-uniting the 2 halves of the bulbo-spongiosus muscle. If haemostasis is secured, the midline skin incision is closed in 2 layers and covered by an occlusive dressing. In the Oxford series a suprapubic cystotomy was performed and a Redivac drain put alongside the anastomosis for 48 h. If it is decided that a one-stage repair is not feasible the midline exposure is still valuable. A viable scrotal flap can still be raised and the midline incision used to obtain access to the urethra, particularly when the scrotal flap is sutured into place.
Fig. 4 The urethral flaps.
Fig. 5 The flaps sutured into position.
fashion 4 flaps which will be interdigitated. The proximal end (mucosa and corpus spongiosum) is incised at 3 o’clock and 9 o’clock and the distal end at 12 o’clock and 6 o’clock (Fig. 4). Closure is made with 310 Dexon (Fig. 5 ) . The sutures are first inserted posteriorly and left long until about 4 are in position. They are tied and a catheter inserted before final urethral closure is
Post-operative Care In the Oxford series a descending cystourethrogram was performed a week post-operatively. If the radiograph was satisfactory, with no extravasation, the suprapubic catheter was clamped and later removed. In Sheffield the urethral catheter was removed between the seventh and tenth days, when a micturating cystourethrogram was performed. It was not considered necessary or desirable to pass sounds post-operatively in either series. Results All patients have been studied post-operatively with an ascending urethrogram and followed up for 3 months to 6 years (Figs. 6 and 7).
Fig. 6 (a) Urethrogram showing complete rupture of the bulbous urethra. (b) Urethrogram 6 months later following end-toend repair.
413
ONE-STAGE EXCISION URETHROPLASTY FOR STRICTURE
Fig. 7 Urethrograms (a) before and (b) after excision and end-to-end repair in a patient with a false passage.
Only 2 patients have had a recurrence of a bulbous stricture: the first followed an infection and abscess formation and he later had a twostage scrotal flap urethroplasty; the second had a further end-toend repair with a successful result. Two patients, who had had a recurrence following a previous end-to-end repair at another centre, both had a successful re-operation with primary suture. In the patient who had 2 strictures 5 cm apart, each was excised separately and primary repair performed. Three patients who had a primary suture for acute rupture of the bulbous urethra within 24 h of injury have all had excellent results. The majority of the urethrograms show remarkably good urethral calibre. In a few some narrowing is shown but dilatation has not been necessary and these patients pass a good stream. One patient has attacks of urinary infection requiring antibiotic therapy.
Discussion The good results of this series of excision and primary end-to-end anastomosis for urethral stricture are almost certainly due to the very careful selection of cases. This operation has the advantage of a one-stage procedure and does not introduce scrotal skin with its sometimes attendant problems of hair formation.
Internal urethrotomy has recently become more popular and a number of our patients may well have been suitable for this procedure. The selection of cases and the results of this operation have yet t o be assessed and compared with primary excision.
Acknowledgement This paper was presented at the Section of Urology at the Royal Society of Medicine, and we are grateful for their permission to publish.
References Blandy, J. P. (1976). Urethroplasty in males. In Recent Advancesin Urology, ed. Hendry, W. F., p. 220. Edinburgh,
London and New York: Churchill Livingstone. Browne, D. ( I 949). Hypospadias. Postgraduate Medical Journal, 25, 367-372. Guyon. F. (1892). De la resection partklle de I’uretre. Revue de chirurgie, 12, 435439. Heusner, D. (1883). Uber Resection der Urethra bei Stricturen. Deutsche medizinische Wochenschriyt, 9.41 5416. Johannson, S. (1953). Reconstruction of the male urethra in stricture. Acta chirurgica Scandinavica, Supplement 176. Marion, G. (1912). De la reconstitution de I’urttre par uretrorraphie circulaire avec derivation de I’urine. Journal d’urologie medicale et chirurgicale. 1, 523-538. Rochet, V. (1899). Nouveau procede pour refaire le canal penien dans I’hypospadias. Gazette hebdomadaire de medecine et de chirurgie, 4, 673-676. Russell, R. H. (1915). The treatment of urethral stricture by excision. British Journal of Surgery, 2, 375-383.
414
The Authors A. Panagakis, MD, Senior House Officer, Department of
Urology, Churchill Hospital. J . C. Smith. MS, FRCS, Consultant Urologist, Churchill Hospital.
BRITISH JOURNAL OF UROLOGY
J . L. Williams, FRCS, Consultant Urologist, Hallamshire Hospital.
Requests for reprints to: J. L. Williams, Department of Urology, Hallamshire Hospital, Glossop Road, Sheffield SIO 2JF.
One-stage Excision Urethroplasty for Stricture A. PANAGAKIS, J. C. SMITH and J. L. WILLIAMS Departments of Urology, Churchill Hospital, Oxford, and Hallamshire Hospital, She ffield
Summary- Forty-two patients have had a one-stage excision urethroplasty for localised strictures in the bulbous urethra. The stricture recurred in 2 patients, one requiring a scrota1 flap urethroplasty and the other a further excision and repair with a good result. With careful selection this operation gives very good results and has been used successfully in the primary repair of complete rupture of the bulbous urethra.
Excision of urethral strictures and primary repair by end-to-end anastomosis were described in the early nineteenth century but the results were unsatisfactory. Heusner (1883) carried out excision and suture and Guyon (1892) excised the stricture incompletely, leaving an intact strip on the posterior urethral wall. Rochet (1 899) advocated urinary diversion and claimed increased success. Russell (1915) excised the stricture and only partially repaired the urethra. He established the principle of the buried strip which was later successfully applied by Browne (1 949) to hypospadias repair, and by Johannson (1953) to the problem of urethral stricture. Marion (1912) used a midline perineal approach for stricture and acute trauma of the bulb. He excised the diseased or damaged tissue and repaired the urethra by direct end -to-end anastomosis. At present, one-stage excision and repair are not popular and Blandy (1976) stated that only 1 in his series of 210 urethroplasties was treated by this method. Eight had been treated by one-stage excision and repair elsewhere and all of these required revision. In contrast with the depressing results which have generally been recorded, ours have been encouraging. Patients Forty-two patients aged from 20 t o 50 years were reviewed. The stricture was bulbar in 41 and penile in 1 patient. One patient had 2 strictures that were 5 cm apart. Received 16 March 1978. Accepted for publication 8 June 1978.
The usual criteria for the failure of conservative management were applied. The one-stage excision and repair were strictly reserved for cases of noninflammatory origin not suitable for internal urethrotomy and in which scarring and damage to the mucosal lining were localised to a short segment. The stricture was usually single and was distal to the external sphincter. A detailed history and a urethrogram of good quality enabled the surgeon to determine whether a case was suitable, but the final decision was made when the stricture had been exposed; if the scarring and diseased mucosa extended for more than 1 cm either side of the stricture, excision of the stricture was not performed. The aetiology was trauma in 17 patients, inflammation in 6, following transurethral resection in 8 and after catheterisation in 2. Three patients were thought to have congenital strictures and in 6 the cause was not known. Operative Technique
Principles Not only must the stricture be excised, but all gross peri-urethral scar must be removed; otherwise a recurrence will probably occur. The cut ends of the urethra, which is divided completely, must reveal healthy mucosa and a normal calibre urethra. It is essential to mobilise the distal urethra so that a tension-free anastomosis can be fashioned and first intention healing ensured. In order to avoid a circumferential scar (which may lead to a recurrence), a zig-zag (Sheffield) or oblique (Oxford) suture line is designed. As the repair cannot be fully water-tight the urine is diverted so that fistula formation and excessive peri-urethral scarring will be avoided. In the
410
41 1
ONE-STAGE EXCISION URETHROPLASTY FOR STRICTURE
Fig. 1 Exposureoftheurethrashowingreflection of the bulbo-spongiosus muscle.
Fig. 2 The stricture opened.
Oxford series a suprapubic cystotomy was used, but in Sheffield an indwelling catheter was relied upon. In both centres 3/0 Dexon was used for suturing. The Operation Under general anaesthesia, with the patient in the exaggerated lithotomy position, a metal sound of large calibre is passed as far as the stricture. A midline perineal incision 4 to 5 cm long is made with the stricture site (as determined by the position of the tip of the sound and the urethrogram) in the centre. The bulbo-spongiosus muscle is divided in the midline, freed from the sheath of the corpus spongiosum which invests the urethra, and held in the blades of a Turner-Warwick selfretaining retractor (Fig. 1). The urethra with its surrounding corpus spongiosum is freed above and below the stricture from the underlying sheath of the corpus cavernosum for a distance of 3 to 4 cm distally and 1 to 2 cm proximally. Only when this has been accomplished and haemostasis secured is the urethra opened in the midline by cutting on to the sound just distal to the stricture for a distance of about 1 cm. Stay sutures are inserted to reveal the urethral lumen
Fig. 3 After excision of the stricture.
and the face of the stricture (Fig. 2). A probe is passed through the stricture and the incision is continued in the midline, dividing the stricture and entering the urethra proximal to the stricture. If the channel is lost in the scar tissue, the careful application of suprapubic pressure may be followed by the escape of urine from the proximal end of the strictured urethra which acts as a guide. Only rarely is it necessary t o have to pass a sound from the bladder into the posterior urethra so that it can be located. It is important to examine the lining mucosa to be certain that the urethra and not a false passage is being followed. The latter has a reddish coloured lining and the passage of an instrument along it is resisted through its whole length. Having opened the proximal urethra it should now be possible to pass a wide-bore sound with ease. If the stricture is localised and the urethra on either side appears healthy the stricture is excised, leaving a gap which should not exceed 2 cm (Fig. 3). If necessary it is now easy to free the distal urethra further by dividing its attachments to the sheath of the corpus cavernosum in the midline. Each cut end of the urethra is cut obliquely or incised in 2 places opposite to each other to
412
BRITISH JOURNAL OF UROLOGY
carried out. Tension on the suture line can be relaxed by suturing the distal urethra to the corpus cavernosum sheath. The repair is covered by re-uniting the 2 halves of the bulbo-spongiosus muscle. If haemostasis is secured, the midline skin incision is closed in 2 layers and covered by an occlusive dressing. In the Oxford series a suprapubic cystotomy was performed and a Redivac drain put alongside the anastomosis for 48 h. If it is decided that a one-stage repair is not feasible the midline exposure is still valuable. A viable scrotal flap can still be raised and the midline incision used to obtain access to the urethra, particularly when the scrotal flap is sutured into place.
Fig. 4 The urethral flaps.
Fig. 5 The flaps sutured into position.
fashion 4 flaps which will be interdigitated. The proximal end (mucosa and corpus spongiosum) is incised at 3 o’clock and 9 o’clock and the distal end at 12 o’clock and 6 o’clock (Fig. 4). Closure is made with 310 Dexon (Fig. 5 ) . The sutures are first inserted posteriorly and left long until about 4 are in position. They are tied and a catheter inserted before final urethral closure is
Post-operative Care In the Oxford series a descending cystourethrogram was performed a week post-operatively. If the radiograph was satisfactory, with no extravasation, the suprapubic catheter was clamped and later removed. In Sheffield the urethral catheter was removed between the seventh and tenth days, when a micturating cystourethrogram was performed. It was not considered necessary or desirable to pass sounds post-operatively in either series. Results All patients have been studied post-operatively with an ascending urethrogram and followed up for 3 months to 6 years (Figs. 6 and 7).
Fig. 6 (a) Urethrogram showing complete rupture of the bulbous urethra. (b) Urethrogram 6 months later following end-toend repair.
413
ONE-STAGE EXCISION URETHROPLASTY FOR STRICTURE
Fig. 7 Urethrograms (a) before and (b) after excision and end-to-end repair in a patient with a false passage.
Only 2 patients have had a recurrence of a bulbous stricture: the first followed an infection and abscess formation and he later had a twostage scrotal flap urethroplasty; the second had a further end-toend repair with a successful result. Two patients, who had had a recurrence following a previous end-to-end repair at another centre, both had a successful re-operation with primary suture. In the patient who had 2 strictures 5 cm apart, each was excised separately and primary repair performed. Three patients who had a primary suture for acute rupture of the bulbous urethra within 24 h of injury have all had excellent results. The majority of the urethrograms show remarkably good urethral calibre. In a few some narrowing is shown but dilatation has not been necessary and these patients pass a good stream. One patient has attacks of urinary infection requiring antibiotic therapy.
Discussion The good results of this series of excision and primary end-to-end anastomosis for urethral stricture are almost certainly due to the very careful selection of cases. This operation has the advantage of a one-stage procedure and does not introduce scrotal skin with its sometimes attendant problems of hair formation.
Internal urethrotomy has recently become more popular and a number of our patients may well have been suitable for this procedure. The selection of cases and the results of this operation have yet t o be assessed and compared with primary excision.
Acknowledgement This paper was presented at the Section of Urology at the Royal Society of Medicine, and we are grateful for their permission to publish.
References Blandy, J. P. (1976). Urethroplasty in males. In Recent Advancesin Urology, ed. Hendry, W. F., p. 220. Edinburgh,
London and New York: Churchill Livingstone. Browne, D. ( I 949). Hypospadias. Postgraduate Medical Journal, 25, 367-372. Guyon. F. (1892). De la resection partklle de I’uretre. Revue de chirurgie, 12, 435439. Heusner, D. (1883). Uber Resection der Urethra bei Stricturen. Deutsche medizinische Wochenschriyt, 9.41 5416. Johannson, S. (1953). Reconstruction of the male urethra in stricture. Acta chirurgica Scandinavica, Supplement 176. Marion, G. (1912). De la reconstitution de I’urttre par uretrorraphie circulaire avec derivation de I’urine. Journal d’urologie medicale et chirurgicale. 1, 523-538. Rochet, V. (1899). Nouveau procede pour refaire le canal penien dans I’hypospadias. Gazette hebdomadaire de medecine et de chirurgie, 4, 673-676. Russell, R. H. (1915). The treatment of urethral stricture by excision. British Journal of Surgery, 2, 375-383.
414
The Authors A. Panagakis, MD, Senior House Officer, Department of
Urology, Churchill Hospital. J . C. Smith. MS, FRCS, Consultant Urologist, Churchill Hospital.
BRITISH JOURNAL OF UROLOGY
J . L. Williams, FRCS, Consultant Urologist, Hallamshire Hospital.
Requests for reprints to: J. L. Williams, Department of Urology, Hallamshire Hospital, Glossop Road, Sheffield SIO 2JF.
