TWO-STAGE
URETHROPLASTY
Improved Method for Treating Bulbomembranous MANUEL
FERNANDES,
JOHN W. DRAPER,
Strictures
M.D.
M.D.
From the Urology Service, St. Luke’s Hospital Center New York, New York
ABSTRACT - Twelve years’ experience with a two-stage urethroplasty for the surgical management of severe and complicated urethral strictures in 200 patients is summarized. The techniques used, including a modification of the]ohanson urethroplasty for bulbomembranous urethral strictures and for multiple strictures without splitting the scrotum, are discussed. The most usual complications of these procedures are reported, as well as how to deal with them, and long-term final results are given. The principles of these procedures are surgically sound, considering the pathology of the strictures. At no time after urethroplasty were urethral dilatations necessary in these 200 patients.
The management of severe and complicated urethral strictures of the male patient continues to be a major urologic problem and a challenge to the urologist. The purpose of this article is to report the late results and complications encountered during our twelve years’ experience with the two-stage urethroplasty in 200 patients. We also wish to present another surgical modification of the Johanson operation, which we have been using since 1967, for strictures involving the bulbomembranous urethra. An effective and surgically sound treatment must be based on knowledge of the underlying pathology. The presence of an inflammatory process in, around, and proximal to the strictured area is usually present. This inflammatory process may be acute, subacute, or chronic.’ The urine from these patients is frequently infected with resistant organisms. Such organisms have been found in 42 per cent of our patients and may be detected at any level of the urinary tract, particularly proximal to the stricture. Johanson in 19532 advised a surgical procedure that required open drainage of the infected strictured area. This procedure allowed the inflammatory process to resolve completely by incising the stricture, well into the normal
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urethra on both sides, and marsupializing the area in the first stage. The second stage reconstruction of the urethra to a normal caliber could be carried out in wellhealed and relatively uninfected tissue (three or more months later). Suprapubic urinary diversion was maintained for both stages of the procedure. Some of the techniques originally described by Johanson were considered to be technically difficult or to have a high incidence of complications. 3-5 Therefore, multiple modifications have been introduced, all using a similar surgical principle. 6-10We also have reported some of our results and complications using these procedures. r1,12 From 1961to 1974, urethroplasties were performed in 200 patients with severe and complicated urethral strictures (58 at Bellevue and 142 at St. Luke’s Hospital). Various modifications of the Johanson operation were used. One hundred thirty-two (66 per cent) of the strictures were thought to be caused by gonorrhea; 15 by transurethral resection of the prostate; 14 by other urethral instrumentation (catheters, scopes, sounds); 11 by external trauma (2 pelvic fractures with ruptured membranous urethra); 2 were considered congenital; 2 secondary to hypospadias repair; 1 due to multiple polyps; 3 recurrent
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From 1961 to 1967, strictures of the bulbomembranous urethra were treated by the inverted “V” perineal flap technique (Leadbetter’s modification of the Johanson first-stage procedure) with a few changes. Because of the high incidence of recurrent strictures (10 per cent) at the proximal stoma with Leadbetter’s technique, we have developed a more reliable technique for posterior strictures. In 82 patients (from 1967 to 1974), this technique was used. It is somewhat different from Blandy’s modification” of Leadbetter’s operation. It consists of four scrotal skin flaps sutured around the marsupialized urethral stricture. The posteriorly based skin flap is shorter than Blandy’s, and the scrotum is never split entirely. Zmproved technique (Fig. 1). The patient is placed in a low lithotomy position. Spinal or epidural anesthesia is recommended, but general anesthesia is occasionally used. An adequate scrotoperineal skin flap, in the shape of an inverted “U,” is outlined using a blue dye. The round apex of this inverted “U” flap is placed in the scrotal raphe approximately 1 inch from the perineal-scrotal junction. The lateral arms may extend down the perineum toward both ischial tuberosities, if necessary for better urethral exposure. The skin is then incised, following the marked lines, and the scrotoperineal flap is raised and dissected well back toward its base. Colles’ fascia is entered longitudinally to expose the bulbocavernosus muscles in the midline. No lateral dissection should be carried out between Colles’ fascia and the bulbocavernosus muscles to avoid bleeding. The bulbocavernosus muscles are divided in the midline and dissected free from the bulb to the urogenital diaphragm. This dissection causes little bleeding, and the bulb back to the membranous urethra is exposed. The urethra is then opened distally to the strictured area over a large bougie a boule. Suture ligatures of 4-O chromic catgut are placed on either side of the urethrotomy, including Buck’s fascia, the full thickness of corpus spongiosum, and urethral mucosa for hemostasis and traction. A grooved director or filiform is passed through the strictured area into the bladder, thus aiding in identifying the urethral lumen after dividing the stricture, Intravenous indigo carmine may be useful in locating the lost lumen. If this is not done, suprapubic diversion may be necessary to find the proximal portion of the urethral lumen. Once the strictured area is divided, the urethrotomy is extended proximally and distally for
strictures following previous urethroplasties, which were performed elsewhere; and in 20 others, the etiology could not be specifically determined. Strictures involved the bulbomembranous urethra in 138 patients; the bulbous and penoscrotal urethra in 35; and the penoscrotal urethra only in 27 patients. Approximately 59 per cent of our 200 patients were black. The age range was from five to eighty-eight fifty and years, most patients being between seventy-nine. A routine medical examination and a thorough urologic examination were performed in each case. A retrograde urethrogram and cystogram with voiding urethrogram were obtained to demonstrate the location, severity, and number of strictures as well as bladder pathology, ureteral reflux, and residual urine. Prior to surgery urethral calibration with bougie h boule or filiforms and urethroscopy were performed. Usually, we prefer not to divert the urine in our patients; but 20 of the 142 patients at St. Luke’s did have urinary diversion by suprapubic cystostomy prior to the first-stage urethroplasty. This type of diversion was necessary in those patients who were in acute urinary retention with impassable strictures or those in whom sepsis developed (1 Escherichia coli, 2 Klebsiella) after urethral instrumentation. Two patients were seen with permanent cystostomy urinary diversion. In all these patients, the cystostomy tubes were removed four or five days after the first-stage urethroplasty. Techniques First stage We have used the original Johanson technique for strictures involving only the penoscrotal urethra with few modifications. At the end of this procedure, the distal and the proximal orifices should calibrate to a 28 F easily. When possible, we do not incise a normal-sized urethral meatus. If the urethral lumen is too narrow (without mucosa or if there are fistulas or abscesses present), this portion of sclerosed corpus spongiosum is excised. If the defect is small, the roof of the urethra is reconstructed by mobilizing and approximating both cut ends and suturing them together in an end to end fashion. If a large portion of the strictured urethra has to be totally excised, the adjacent skin is sutured across the gap edge to edge. This total excision of the strictured urethra was performed in only 2 patients and gave good functional results.
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1975 / VOLUME
VI, NUMBER
5
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BLILBOCAVERNOSUS CORPUS
M.
CAVERNOSU
URETHRAL
MUCOSA
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CANAL
FIGURE 1. Technique for bulbomembranous strictures. (A) Scrotal perinealjap, lateral scrotal flaps, and small distal flap are outlined. (B) Scrotal perineal flap raised, and incision of Colles’ fascia and bulbocavernosus muscle. (C) Strictured area incised. (D) Suture of scrotal perinealtip. (E) Flap sutured in place and raised lateral scrotal flaps and small distal “V” flap. (F) Entire marsupialization of urethra completed.
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more than 1 cm. into the normal lumen of the urethra (often the proximal end of the urethrotomy reaches the membranous urethra and in a few instances (4 cases) extends through it. Again, scar tissue with abscesses or fistulous tracts are surgically excised, and when necessary continuity of the roof of the urethra accomplished by end to end suturing. Both urethral orifices should calibrate to 30 F easily. The scrotoperineal flap is then inserted into the proximal gap of the urethrotomy (Fig. 1D). To do this, one suture of 3-O chromic catgut is first passed in the midline of the proximal orifice of the urethra and through the apex of the skin flap (generous bite - 3 mm. from the edges). Two more supporting full-thickness sutures are passed on either side of the urethrotomy, close to the first one and through the apex of the skin flap. The knots are all within the urethral lumen. These are the key sutures and must be tied down with special care to establish good apposition of the skin and mucosal edges and so prevent recurrences at this critical and difficult area. The skin edges of the lateral borders of the scrotal flap are now approximated to the urethral edges with interrupted sutures of 4-O chromic catgut until reaching the perineal level. The midline incision along the scrotal raphe is now made according to the length of the area to be marsupialized (Fig. 1E). This midline incision will establish two large scrotal skin flaps laterally, which are then mobilized. The apex of each one of these skin flaps is brought down toward the established angle between the opened urethra and the scrotoperineal flap, “Y” to “Y,” and sutured at this level to the urethral edges and to the skin edges without tension. Special care is also given to the approximation of the small “V” scrotal skin flap to the distal stoma (Fig. lF[Z]); the lateral side of the skin edges are proximated to the mucosal edges with interrupted 4-O chromic catgut sutures. In the completed procedure the skin surrounding the entire marsupialized urethra is pliable, elastic, fat-free scrotal skin, made by joining the four scrotal flaps described. An 18 F Foley catheter is introduced into the bladder through the proximal stoma and left indwelling for three to four days. Vaseline gauze is packed around the catheter and into the distal stoma. No rubber drains are used. A sterile pressure dressing is applied for about forty-eight hours. Postoperative care must be aggressive with perineal care (sitz baths and warm air blower) to keep the wound clean and dry.
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For the long penoscrotobulbomembranous strictures, we use the Johanson and scrotoperineal flap techniques together, resulting in a few cases, in complete bridging of the scrotum rather than splitting it (Fig. 2). We delay the second operation for weeks or months (average eight to twelve weeks) until the inflammatory reaction has subsided and the tissues are well healed. Cystopanendoscopy must be done in all cases to rule out bladder neck obstruction or other pathologic changes in the bladder. A transurethral resection, when necessary, should precede the second stage by at least four weeks. Approximately 60 per cent of our patients had transurethral resections of the prostate for bladder neck contraction or benign prostatic hyperplasia; and in 7 patients, occult carcinoma was found. Eight other patients had transurethral resections for benign prostatic hyperplasia two years or more after the urethroplasties. Prior to the second-stage closure, the urethroplasty stomas were carefully calibrated. Preferably, a 28 F should pass into both stomas easily; however, a 26 F has been considered adequate for good results. If recurrent stoma1 strictures are found, revision must be carried out before final closure. Second
stage
Most of our patients were treated with our single-layer closure. 11p12This single-layer closure is a simple modification of the Dennis-Browne procedure. Two thick lateral flaps are developed and closed over a 3-cm. wide strip of skin and urethral mucosa with a single continuous 1-O monofilament nylon suture. This method of closure avoids formation of dead spaces found in multiple layers and so minimizes trapping bacteria with infection and resulting fistula formation. Results and Complications At first-stage urethroplasty was performed in 200 patients. Of these, 27 underwent the Johanson procedure; 76, the Leadbetter modification; 62, the improved scrotoperineal flap technique; 15, a combination of Leadbetter and Johanson; and 20, a combination of the improved scrotoperineal flap and Johanson procedure for multiple strictures (in 5 ofwhich the scrotum was bridged). Stoma1 strictures occurred in 9 of the 27 patients (33 per cent) who had the Johanson procedure: 3 at the proximal stoma, and 6 at the distal stoma. One patient had disruption of the
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i CJ
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INTRASCROTAL CONNECTIVE
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OK ON ANTERIOR SCROTAL
SKIN
F. FIGURES. Technique for multiple urethral strictures that involve penile and bulbous urethra. (A) Incision of pendulous urethral stricture. (B) Marsupialization of urethra with sutures approximating urethral mucosal edges to skin edges. (C) Scrotal perinealfips raised. (D) incision of bulbous stricture and anterior scrotal skin brought underneath scrotum. (E) Suture of scrotal perineal flaps into proximal gap of urethrotomy. (F) Completed procedure showing both anterior and posterior marsupialization of urethra with scrotal bridge.
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urethroplasty due to hematoma formation. Stoma1 strictures occurred in 17 of the 91 patients (20 per cent) who had Leadbetter’s modification or the combined Leadbetter-Johanson procedure. One patient had disruption of the wound due to severe infection. Eight strictures were at the distal stoma and were easily revised. Nine strictures (10 per cent) were at the proximal stoma and were revised by our method (scrotoperineal lateral flap technique). This is a major procedure and difficult to execute properly.12 Stoma1 strictures occurred in only 10 of the 82 patients (12 per cent) who had our scrotoperineal skin flap technique and/or combination with the Johanson procedure. Seven strictures were at the distal stoma and 3 (3.6 per cent) were encountered at the proximal stoma but were easily revised by first lifting up the skin flap, incising the strictured stoma, and resuturing the inlay skin flap. One of these patients required two revisions. The second stage was performed in 185 patients. A Cecil closure was performed in 3; fourteen (7 Johanson and 7 Leadbetter) had conventional multiple-layer closures; and 168 (20 penile and 115 perineal, and 33 combination of both) had our single-layer closure. There were 9 patients in whom the second stage was unjustified or refused. Six patients are awaiting closure. Early complications (within six months) encountered in the 14 patients with multiplelayer closure were: 3 patients had large bore stricture; 2 had periurethral abscesses with resulting large diverticula; and 3 had urethral cutaneous fistulas which required multiple procedures for closure. One of the 3 patients who had a Cecil closure had a urethrocutaneous fistula that required surgical repair. In another, recurrent stricture developed at the proximal area (penoscrotal junction) six months after closure, requiring reoperation by the same two-stage Johanson procedure. One hundred sixty-eight patients had our single-layer closure (135 patients were at St. Luke’s Hospital Center) and 80 (59 per cent) had no complications in any of the stages, even though 57 had transurethral resections of the prostate between the first and second stage, using a 28 F resectoscope. Of the remaining 88 patients, urethrocutaneous fistulas which required surgical closure developed in 3. Ten patients had temporary leakage which stopped without aid of catheter or surgery. There were 2 recurrent large bore strictures (18 F) that occurred two years after
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closure following transurethral resections of the prostate, and one restricture following transurethral resection of the prostate five years after closure. This patient underwent another firststage perineal urethroplasty. In 3 other patients large urethral diverticula developed, 1 at the bulb and 2 at the penile urethroplasty. One of the latter patients required excision of the diverticulum. In another patient recurrent strictures developed one year following penile urethroplasty requiring reoperation.
VI, NUMBER 5
Follow-up Of the 185 patients with completed urethroplasties, 157 came to follow-up. Follow-up at St. Luke’s Hospital Center has been excellent; of the I38 patients, only 3 were lost to follow-up. Seven patients were followed up for more than seven years (3, more than eight years); 17 patients have been followed up for more than five years, 26 more than three years, 16 more than two years, 27 more than one year, and 66 less than one year. Eleven patients have died of causes unrelated to their urethroplasties at one, two, three, and over seven years after their procedures. Two others died before the first year. Urethrograms were performed routinely in all patients who were followed up for more than six months, and at yearly intervals thereafter. Twenty-four of the 46 patients who have had three to over seven years of follow-up have undergone panendoscopy. Thin hair, six to eight, seen on the inverted scrotal skin or perineal skin have been found without incrustation or stone formation. In 13 other patients who have been followed up for more than two years, 10 also had panendoscopic examination; the hairs were thicker and longer, and one stone was found but this patient had a history of stone formation. Transurethral resection of the prostate was performed on 8 patients for symptoms of recurrent prostatism. In 3 of these patients recurrent strictures developed later and one required reoperation. To date, no patient has ever required urethral soundings after the completion of urethroplasty. No case of sexual impotence or urinary incontinence has been considered to be a result of this procedure. There was failure of forceful ejaculation in 1 patient and chordee in another. In 3 patients invasive carcinoma of the bladder developed two years after completion of the procedure.
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FIGURE 3. Retrograde urethrogram. (A) Preoperative showing multiple bulbous strictures; (B) postoperative (seven years later) demonstrating normal caliber urethra.
FIGURE 4. Retrograde urethrogram. (A) Preoperative demonstrating strictures of bulb; (B) postoperative (six years later) showing normal caliber urethra.
No special skill is required to perform this procedure. The majority of these patients have been operated on by members of our resident staff under our supervision. Persistent pyuria has been found in approximately 25 per cent of these patients; however,
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urine cultures usually have been sterile. Recurrent symptomatic urinary infections have occurred occasionally but have been easily controlled with antibiotic therapy. The urinary stream is good to excellent in the majority of the patients (Figs. 3 and 4).
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In conclusion, this improved scrotal perineal technique for the first stage offered several advantages. It is easier to perform; deeper strictures can be reached and the inlay flap sutured without tension, so the stoma1 strictures are less common and are easier to revise; and the scrotum is never split entirely and affords better healing of the marsupialized area. Transurethral resection of the prostate should be avoided in these patients after urethral repair is completed since the incidence of recurrent strictures is high. Cystopanendoscopy should be performed every two years at least as a followup for evaluation of the reconstructed urethra and possibility of coexistent bladder pathology, such as bladder tumors in the early stage. Although the number of complications encountered with this procedure are numerous, the final long-term results have been gratifying. Amsterdam Avenue at 114th Street New York, New York 10025 (DR. DRAPER)
779 (1966).
References 1. BEARD, D. D., and GOODYEAR, W. E.: Urethral stricture: a pathological study, J. Urol. 59: 619 (1948). of the male urethra in 2. JOHANSON, B. : Reconstruction
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strictures, Acta Chir. Stand. [Suppl.] 1: 176 (1953). 3. CULP, D. A., FLOCKS, R. H., KROAWETTER, H., and MARBERGER, H.: Experiences with the JohansonDennis-Browne technique of urethroplasty, J. Urol. 77: 446 (1957). 4. GERLAUGH, R. L., RATTNER, W. H., and MURPHY, J. J.: Late results of urethroplasty for stricture, ibid. 81: 763 (1959). 5. KAUFMAN, J. J., PEARMAN, R. O., and GOODWIN, W. E. : Complications of the Johanson operation in the repair of urethral strictures, ibid. 87: 883 (1962). modification of Johanson 6. LAPIDES, J.: Simplified urethroplasty for strictures of deep bulbous urethra, ibid. 82: 115 (1959). 7. LEADBE?TER, G. W., JR. : A simplified urethroplasty for strictures of the bulbous urethra, ibid. 83: 54 (1969). 8. GIL-VERNET, J. M.: Un traitement des stenoses traumatiques et inflammatoires de 1’uretere posterieur. Nouvelle methode d’ urethroplastie, J. d’ Urol. Nephrol. 72: 97 (1966). 9. TURNER-WARWICK, R. T.: The repair of strictures in the region of the membranous urethra, J. Ural. 100: 303 (1968). 10. BLANDY, J. P., SINGH, M., and TRESIDDER, G. C.: Urethroplasty by scrotal flap for long urethral strictures, Br. J. Urol. 40: 261 (1968). 11. FERNANDES, M., ORANDI, A., and DRAPER, J. W.: Urethroplasty: a new method of closure, J. Urol. 96:
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12. FERNANDES, M., and DRAPER, J. W.: Urethroplasty: results, complications and long-term follow up of single layer closure and a new method for revision of recurrent strictures, ibid. 101:325 (1969).
575
URETHROPLASTY
Improved Method for Treating Bulbomembranous MANUEL
FERNANDES,
JOHN W. DRAPER,
Strictures
M.D.
M.D.
From the Urology Service, St. Luke’s Hospital Center New York, New York
ABSTRACT - Twelve years’ experience with a two-stage urethroplasty for the surgical management of severe and complicated urethral strictures in 200 patients is summarized. The techniques used, including a modification of the]ohanson urethroplasty for bulbomembranous urethral strictures and for multiple strictures without splitting the scrotum, are discussed. The most usual complications of these procedures are reported, as well as how to deal with them, and long-term final results are given. The principles of these procedures are surgically sound, considering the pathology of the strictures. At no time after urethroplasty were urethral dilatations necessary in these 200 patients.
The management of severe and complicated urethral strictures of the male patient continues to be a major urologic problem and a challenge to the urologist. The purpose of this article is to report the late results and complications encountered during our twelve years’ experience with the two-stage urethroplasty in 200 patients. We also wish to present another surgical modification of the Johanson operation, which we have been using since 1967, for strictures involving the bulbomembranous urethra. An effective and surgically sound treatment must be based on knowledge of the underlying pathology. The presence of an inflammatory process in, around, and proximal to the strictured area is usually present. This inflammatory process may be acute, subacute, or chronic.’ The urine from these patients is frequently infected with resistant organisms. Such organisms have been found in 42 per cent of our patients and may be detected at any level of the urinary tract, particularly proximal to the stricture. Johanson in 19532 advised a surgical procedure that required open drainage of the infected strictured area. This procedure allowed the inflammatory process to resolve completely by incising the stricture, well into the normal
568
urethra on both sides, and marsupializing the area in the first stage. The second stage reconstruction of the urethra to a normal caliber could be carried out in wellhealed and relatively uninfected tissue (three or more months later). Suprapubic urinary diversion was maintained for both stages of the procedure. Some of the techniques originally described by Johanson were considered to be technically difficult or to have a high incidence of complications. 3-5 Therefore, multiple modifications have been introduced, all using a similar surgical principle. 6-10We also have reported some of our results and complications using these procedures. r1,12 From 1961to 1974, urethroplasties were performed in 200 patients with severe and complicated urethral strictures (58 at Bellevue and 142 at St. Luke’s Hospital). Various modifications of the Johanson operation were used. One hundred thirty-two (66 per cent) of the strictures were thought to be caused by gonorrhea; 15 by transurethral resection of the prostate; 14 by other urethral instrumentation (catheters, scopes, sounds); 11 by external trauma (2 pelvic fractures with ruptured membranous urethra); 2 were considered congenital; 2 secondary to hypospadias repair; 1 due to multiple polyps; 3 recurrent
UROLOGY
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/
VOLUME
VI, NUMBER
5
From 1961 to 1967, strictures of the bulbomembranous urethra were treated by the inverted “V” perineal flap technique (Leadbetter’s modification of the Johanson first-stage procedure) with a few changes. Because of the high incidence of recurrent strictures (10 per cent) at the proximal stoma with Leadbetter’s technique, we have developed a more reliable technique for posterior strictures. In 82 patients (from 1967 to 1974), this technique was used. It is somewhat different from Blandy’s modification” of Leadbetter’s operation. It consists of four scrotal skin flaps sutured around the marsupialized urethral stricture. The posteriorly based skin flap is shorter than Blandy’s, and the scrotum is never split entirely. Zmproved technique (Fig. 1). The patient is placed in a low lithotomy position. Spinal or epidural anesthesia is recommended, but general anesthesia is occasionally used. An adequate scrotoperineal skin flap, in the shape of an inverted “U,” is outlined using a blue dye. The round apex of this inverted “U” flap is placed in the scrotal raphe approximately 1 inch from the perineal-scrotal junction. The lateral arms may extend down the perineum toward both ischial tuberosities, if necessary for better urethral exposure. The skin is then incised, following the marked lines, and the scrotoperineal flap is raised and dissected well back toward its base. Colles’ fascia is entered longitudinally to expose the bulbocavernosus muscles in the midline. No lateral dissection should be carried out between Colles’ fascia and the bulbocavernosus muscles to avoid bleeding. The bulbocavernosus muscles are divided in the midline and dissected free from the bulb to the urogenital diaphragm. This dissection causes little bleeding, and the bulb back to the membranous urethra is exposed. The urethra is then opened distally to the strictured area over a large bougie a boule. Suture ligatures of 4-O chromic catgut are placed on either side of the urethrotomy, including Buck’s fascia, the full thickness of corpus spongiosum, and urethral mucosa for hemostasis and traction. A grooved director or filiform is passed through the strictured area into the bladder, thus aiding in identifying the urethral lumen after dividing the stricture, Intravenous indigo carmine may be useful in locating the lost lumen. If this is not done, suprapubic diversion may be necessary to find the proximal portion of the urethral lumen. Once the strictured area is divided, the urethrotomy is extended proximally and distally for
strictures following previous urethroplasties, which were performed elsewhere; and in 20 others, the etiology could not be specifically determined. Strictures involved the bulbomembranous urethra in 138 patients; the bulbous and penoscrotal urethra in 35; and the penoscrotal urethra only in 27 patients. Approximately 59 per cent of our 200 patients were black. The age range was from five to eighty-eight fifty and years, most patients being between seventy-nine. A routine medical examination and a thorough urologic examination were performed in each case. A retrograde urethrogram and cystogram with voiding urethrogram were obtained to demonstrate the location, severity, and number of strictures as well as bladder pathology, ureteral reflux, and residual urine. Prior to surgery urethral calibration with bougie h boule or filiforms and urethroscopy were performed. Usually, we prefer not to divert the urine in our patients; but 20 of the 142 patients at St. Luke’s did have urinary diversion by suprapubic cystostomy prior to the first-stage urethroplasty. This type of diversion was necessary in those patients who were in acute urinary retention with impassable strictures or those in whom sepsis developed (1 Escherichia coli, 2 Klebsiella) after urethral instrumentation. Two patients were seen with permanent cystostomy urinary diversion. In all these patients, the cystostomy tubes were removed four or five days after the first-stage urethroplasty. Techniques First stage We have used the original Johanson technique for strictures involving only the penoscrotal urethra with few modifications. At the end of this procedure, the distal and the proximal orifices should calibrate to a 28 F easily. When possible, we do not incise a normal-sized urethral meatus. If the urethral lumen is too narrow (without mucosa or if there are fistulas or abscesses present), this portion of sclerosed corpus spongiosum is excised. If the defect is small, the roof of the urethra is reconstructed by mobilizing and approximating both cut ends and suturing them together in an end to end fashion. If a large portion of the strictured urethra has to be totally excised, the adjacent skin is sutured across the gap edge to edge. This total excision of the strictured urethra was performed in only 2 patients and gave good functional results.
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/ NOVEMBER
1975 / VOLUME
VI, NUMBER
5
569
BLILBOCAVERNOSUS CORPUS
M.
CAVERNOSU
URETHRAL
MUCOSA
URETHRAL
CANAL
FIGURE 1. Technique for bulbomembranous strictures. (A) Scrotal perinealjap, lateral scrotal flaps, and small distal flap are outlined. (B) Scrotal perineal flap raised, and incision of Colles’ fascia and bulbocavernosus muscle. (C) Strictured area incised. (D) Suture of scrotal perinealtip. (E) Flap sutured in place and raised lateral scrotal flaps and small distal “V” flap. (F) Entire marsupialization of urethra completed.
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more than 1 cm. into the normal lumen of the urethra (often the proximal end of the urethrotomy reaches the membranous urethra and in a few instances (4 cases) extends through it. Again, scar tissue with abscesses or fistulous tracts are surgically excised, and when necessary continuity of the roof of the urethra accomplished by end to end suturing. Both urethral orifices should calibrate to 30 F easily. The scrotoperineal flap is then inserted into the proximal gap of the urethrotomy (Fig. 1D). To do this, one suture of 3-O chromic catgut is first passed in the midline of the proximal orifice of the urethra and through the apex of the skin flap (generous bite - 3 mm. from the edges). Two more supporting full-thickness sutures are passed on either side of the urethrotomy, close to the first one and through the apex of the skin flap. The knots are all within the urethral lumen. These are the key sutures and must be tied down with special care to establish good apposition of the skin and mucosal edges and so prevent recurrences at this critical and difficult area. The skin edges of the lateral borders of the scrotal flap are now approximated to the urethral edges with interrupted sutures of 4-O chromic catgut until reaching the perineal level. The midline incision along the scrotal raphe is now made according to the length of the area to be marsupialized (Fig. 1E). This midline incision will establish two large scrotal skin flaps laterally, which are then mobilized. The apex of each one of these skin flaps is brought down toward the established angle between the opened urethra and the scrotoperineal flap, “Y” to “Y,” and sutured at this level to the urethral edges and to the skin edges without tension. Special care is also given to the approximation of the small “V” scrotal skin flap to the distal stoma (Fig. lF[Z]); the lateral side of the skin edges are proximated to the mucosal edges with interrupted 4-O chromic catgut sutures. In the completed procedure the skin surrounding the entire marsupialized urethra is pliable, elastic, fat-free scrotal skin, made by joining the four scrotal flaps described. An 18 F Foley catheter is introduced into the bladder through the proximal stoma and left indwelling for three to four days. Vaseline gauze is packed around the catheter and into the distal stoma. No rubber drains are used. A sterile pressure dressing is applied for about forty-eight hours. Postoperative care must be aggressive with perineal care (sitz baths and warm air blower) to keep the wound clean and dry.
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For the long penoscrotobulbomembranous strictures, we use the Johanson and scrotoperineal flap techniques together, resulting in a few cases, in complete bridging of the scrotum rather than splitting it (Fig. 2). We delay the second operation for weeks or months (average eight to twelve weeks) until the inflammatory reaction has subsided and the tissues are well healed. Cystopanendoscopy must be done in all cases to rule out bladder neck obstruction or other pathologic changes in the bladder. A transurethral resection, when necessary, should precede the second stage by at least four weeks. Approximately 60 per cent of our patients had transurethral resections of the prostate for bladder neck contraction or benign prostatic hyperplasia; and in 7 patients, occult carcinoma was found. Eight other patients had transurethral resections for benign prostatic hyperplasia two years or more after the urethroplasties. Prior to the second-stage closure, the urethroplasty stomas were carefully calibrated. Preferably, a 28 F should pass into both stomas easily; however, a 26 F has been considered adequate for good results. If recurrent stoma1 strictures are found, revision must be carried out before final closure. Second
stage
Most of our patients were treated with our single-layer closure. 11p12This single-layer closure is a simple modification of the Dennis-Browne procedure. Two thick lateral flaps are developed and closed over a 3-cm. wide strip of skin and urethral mucosa with a single continuous 1-O monofilament nylon suture. This method of closure avoids formation of dead spaces found in multiple layers and so minimizes trapping bacteria with infection and resulting fistula formation. Results and Complications At first-stage urethroplasty was performed in 200 patients. Of these, 27 underwent the Johanson procedure; 76, the Leadbetter modification; 62, the improved scrotoperineal flap technique; 15, a combination of Leadbetter and Johanson; and 20, a combination of the improved scrotoperineal flap and Johanson procedure for multiple strictures (in 5 ofwhich the scrotum was bridged). Stoma1 strictures occurred in 9 of the 27 patients (33 per cent) who had the Johanson procedure: 3 at the proximal stoma, and 6 at the distal stoma. One patient had disruption of the
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i CJ
ORPUS
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fi
’
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F. FIGURES. Technique for multiple urethral strictures that involve penile and bulbous urethra. (A) Incision of pendulous urethral stricture. (B) Marsupialization of urethra with sutures approximating urethral mucosal edges to skin edges. (C) Scrotal perinealfips raised. (D) incision of bulbous stricture and anterior scrotal skin brought underneath scrotum. (E) Suture of scrotal perineal flaps into proximal gap of urethrotomy. (F) Completed procedure showing both anterior and posterior marsupialization of urethra with scrotal bridge.
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urethroplasty due to hematoma formation. Stoma1 strictures occurred in 17 of the 91 patients (20 per cent) who had Leadbetter’s modification or the combined Leadbetter-Johanson procedure. One patient had disruption of the wound due to severe infection. Eight strictures were at the distal stoma and were easily revised. Nine strictures (10 per cent) were at the proximal stoma and were revised by our method (scrotoperineal lateral flap technique). This is a major procedure and difficult to execute properly.12 Stoma1 strictures occurred in only 10 of the 82 patients (12 per cent) who had our scrotoperineal skin flap technique and/or combination with the Johanson procedure. Seven strictures were at the distal stoma and 3 (3.6 per cent) were encountered at the proximal stoma but were easily revised by first lifting up the skin flap, incising the strictured stoma, and resuturing the inlay skin flap. One of these patients required two revisions. The second stage was performed in 185 patients. A Cecil closure was performed in 3; fourteen (7 Johanson and 7 Leadbetter) had conventional multiple-layer closures; and 168 (20 penile and 115 perineal, and 33 combination of both) had our single-layer closure. There were 9 patients in whom the second stage was unjustified or refused. Six patients are awaiting closure. Early complications (within six months) encountered in the 14 patients with multiplelayer closure were: 3 patients had large bore stricture; 2 had periurethral abscesses with resulting large diverticula; and 3 had urethral cutaneous fistulas which required multiple procedures for closure. One of the 3 patients who had a Cecil closure had a urethrocutaneous fistula that required surgical repair. In another, recurrent stricture developed at the proximal area (penoscrotal junction) six months after closure, requiring reoperation by the same two-stage Johanson procedure. One hundred sixty-eight patients had our single-layer closure (135 patients were at St. Luke’s Hospital Center) and 80 (59 per cent) had no complications in any of the stages, even though 57 had transurethral resections of the prostate between the first and second stage, using a 28 F resectoscope. Of the remaining 88 patients, urethrocutaneous fistulas which required surgical closure developed in 3. Ten patients had temporary leakage which stopped without aid of catheter or surgery. There were 2 recurrent large bore strictures (18 F) that occurred two years after
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closure following transurethral resections of the prostate, and one restricture following transurethral resection of the prostate five years after closure. This patient underwent another firststage perineal urethroplasty. In 3 other patients large urethral diverticula developed, 1 at the bulb and 2 at the penile urethroplasty. One of the latter patients required excision of the diverticulum. In another patient recurrent strictures developed one year following penile urethroplasty requiring reoperation.
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Follow-up Of the 185 patients with completed urethroplasties, 157 came to follow-up. Follow-up at St. Luke’s Hospital Center has been excellent; of the I38 patients, only 3 were lost to follow-up. Seven patients were followed up for more than seven years (3, more than eight years); 17 patients have been followed up for more than five years, 26 more than three years, 16 more than two years, 27 more than one year, and 66 less than one year. Eleven patients have died of causes unrelated to their urethroplasties at one, two, three, and over seven years after their procedures. Two others died before the first year. Urethrograms were performed routinely in all patients who were followed up for more than six months, and at yearly intervals thereafter. Twenty-four of the 46 patients who have had three to over seven years of follow-up have undergone panendoscopy. Thin hair, six to eight, seen on the inverted scrotal skin or perineal skin have been found without incrustation or stone formation. In 13 other patients who have been followed up for more than two years, 10 also had panendoscopic examination; the hairs were thicker and longer, and one stone was found but this patient had a history of stone formation. Transurethral resection of the prostate was performed on 8 patients for symptoms of recurrent prostatism. In 3 of these patients recurrent strictures developed later and one required reoperation. To date, no patient has ever required urethral soundings after the completion of urethroplasty. No case of sexual impotence or urinary incontinence has been considered to be a result of this procedure. There was failure of forceful ejaculation in 1 patient and chordee in another. In 3 patients invasive carcinoma of the bladder developed two years after completion of the procedure.
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FIGURE 3. Retrograde urethrogram. (A) Preoperative showing multiple bulbous strictures; (B) postoperative (seven years later) demonstrating normal caliber urethra.
FIGURE 4. Retrograde urethrogram. (A) Preoperative demonstrating strictures of bulb; (B) postoperative (six years later) showing normal caliber urethra.
No special skill is required to perform this procedure. The majority of these patients have been operated on by members of our resident staff under our supervision. Persistent pyuria has been found in approximately 25 per cent of these patients; however,
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urine cultures usually have been sterile. Recurrent symptomatic urinary infections have occurred occasionally but have been easily controlled with antibiotic therapy. The urinary stream is good to excellent in the majority of the patients (Figs. 3 and 4).
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In conclusion, this improved scrotal perineal technique for the first stage offered several advantages. It is easier to perform; deeper strictures can be reached and the inlay flap sutured without tension, so the stoma1 strictures are less common and are easier to revise; and the scrotum is never split entirely and affords better healing of the marsupialized area. Transurethral resection of the prostate should be avoided in these patients after urethral repair is completed since the incidence of recurrent strictures is high. Cystopanendoscopy should be performed every two years at least as a followup for evaluation of the reconstructed urethra and possibility of coexistent bladder pathology, such as bladder tumors in the early stage. Although the number of complications encountered with this procedure are numerous, the final long-term results have been gratifying. Amsterdam Avenue at 114th Street New York, New York 10025 (DR. DRAPER)
779 (1966).
References 1. BEARD, D. D., and GOODYEAR, W. E.: Urethral stricture: a pathological study, J. Urol. 59: 619 (1948). of the male urethra in 2. JOHANSON, B. : Reconstruction
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strictures, Acta Chir. Stand. [Suppl.] 1: 176 (1953). 3. CULP, D. A., FLOCKS, R. H., KROAWETTER, H., and MARBERGER, H.: Experiences with the JohansonDennis-Browne technique of urethroplasty, J. Urol. 77: 446 (1957). 4. GERLAUGH, R. L., RATTNER, W. H., and MURPHY, J. J.: Late results of urethroplasty for stricture, ibid. 81: 763 (1959). 5. KAUFMAN, J. J., PEARMAN, R. O., and GOODWIN, W. E. : Complications of the Johanson operation in the repair of urethral strictures, ibid. 87: 883 (1962). modification of Johanson 6. LAPIDES, J.: Simplified urethroplasty for strictures of deep bulbous urethra, ibid. 82: 115 (1959). 7. LEADBE?TER, G. W., JR. : A simplified urethroplasty for strictures of the bulbous urethra, ibid. 83: 54 (1969). 8. GIL-VERNET, J. M.: Un traitement des stenoses traumatiques et inflammatoires de 1’uretere posterieur. Nouvelle methode d’ urethroplastie, J. d’ Urol. Nephrol. 72: 97 (1966). 9. TURNER-WARWICK, R. T.: The repair of strictures in the region of the membranous urethra, J. Ural. 100: 303 (1968). 10. BLANDY, J. P., SINGH, M., and TRESIDDER, G. C.: Urethroplasty by scrotal flap for long urethral strictures, Br. J. Urol. 40: 261 (1968). 11. FERNANDES, M., ORANDI, A., and DRAPER, J. W.: Urethroplasty: a new method of closure, J. Urol. 96:
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12. FERNANDES, M., and DRAPER, J. W.: Urethroplasty: results, complications and long-term follow up of single layer closure and a new method for revision of recurrent strictures, ibid. 101:325 (1969).
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