Patients with extensive posttraumatic bulbo-membranous urethral defects or strictures are uncommon. patients who have undergone prior failed surgeries or who have developed secondary urethral infection pose the most challenging problem in modern urology. Grafts and flaps are frequently used for the treatment of a long complex urethral strictures (1-10). However, their application may be impossible because of the poor quality of the urethral bed or scarred perineoscrotal skin caused by repeated failed surgery; this further increases the failure rate. Enterourethroplasty, using the appendix, a jejunal free flap, the ileum, the stomach, or a sigmoid colon flap, has been reported for the treatment of complex and lengthy bulbo-membranous urethral defects or strictures (11-14). However, these techniques are not universally applicable because they require experience and expertise with microvascular anastomosis.
In 2007, we reported the initial outcomes of staged pendulous-prostatic anastomotic urethroplasty on two patients with posttraumatic complex bulbo-membranous urethral lengthy defects with good outcomes (15). The present report describes our surgical experience on 20 patients with posttraumatic extensive bulbo-membranous urethral defects or strictures who underwent 2 to 12 unsuccessful repairs. We present the following article in accordance with the STROBE reporting checklist (available at http://dx.doi.org/10.21037/tau-20-1024).
Between January 2002 and December 2018, 20 patients (mean age 40.2, range 12 to 61 years) with complex long-segment defects or strictures of the bulbo-membranous urethra and scarred perineoscrotal skin underwent a procedure of transposition of the penis to the perineum with penile-prostatic anastomotic urethroplasty. The etiology of urethral stricture or defect was trauma in all patients. The causes of injury included traffic accidents in thirteen, injury by falling in four, crush injuries in two, and an electrical shock injury in one patient (Table 1). All patients were initially treated elsewhere. The mean time between original injury and admission to our hospital was 7.8 (range 2 to 31) years. Prior to admission, suprapubic cystostomy had been performed in all patients. Patients had undergone between 2 and 12 (mean 4.5) unsuccessful repairs, including anastomotic urethroplasty, flap substitution urethroplasty, and urethrotomy. The mean length of the urethral stricture or defect was 8.6 (mean 7.5–11) cm (Figure 1). Five (25%) patients were associated urethrorectal fistula. A colostomy was used in patients with concomitant recto-urethral fistula. Sixteen (80%) patients reported severe penile erectile dysfunction (PED) or no penile erectile at any time before admission and the remaining 4 (20%) reported partial erections. All patients were scheduled to be examined in the outpatient clinic 1, 3, 6, 12 months postoperatively. One year after the operation, we call the patients each year to ask if they have dysuria. All patients were followed up. If patient feel dysuria, urethrography and urethroscopy were performed to rule out a stricture. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). When this technology was applied 18 years ago, our country didn’t have a complete Institutional Review Board (IRB) system. Therefore, the ethical approval is not required. Informed consent was obtained from the patients.
Twenty patients underwent transposition of the penis to the perineum with penile-prostatic anastomotic urethroplasty. The patients were placed in the standard lithotomy position after induction of general anesthesia. An inverted Y-shaped perineal incision was made, extending anteriorly to the scrotum and penis. The obliterated urethra and periurethral fibrotic tissues were completely excised until a healthy prostatic urethra was identified (Figure 2A). A circular skin incision around the base of the penis was made, maintaining the blood supply of the spongy body of the penis. The penis was transposed to the perineum through a scrotal septum incision or tunnel (Figure 2B) and the length of the normal penile urethra (LNPU) was approximately 6–9 cm (Figure 2C). The penile urethra was anastomosed to the prostatic urethra under tension-free conditions using of 3-4/0 polyglycolic acid sutures. The penis was displaced under the scrotum postoperatively (Figure 3A).
Nine patients have received a secondary penile straightening procedure. This operation was performed at least 6 months later when the anterior urethra was revascularized from periurethral tissue. The second procedure involved straightening the penis and one-stage anterior urethral reconstruction using a penile circular fasciocutaneous skin flap. The curved spongy body of the penis was separated, the urethra was transected at the site of the coronary sulcus, and the spongy body was straightened. A new anterior urethra was reconstructed using a penile circular fasciocutaneous skin flap.
Five patients received the third-stage surgery. This operation was reconstruction of a new anterior urethra using second-stage Johanson urethroplasty. It was performed 6 months after the second surgery. 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 1.2–1.5 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. The ventral side of the new urethra was left to become epithelialized. This three-step technique was described before (15).
Treatment of urethrorectal fistulas
Five patients had urethral strictures associated with a urethrorectal fistula, repaired simultaneously during the first procedure. The ﬁstula was dissected circumferentially and excised completely; the margins of the ﬁstulous opening in the rectum were freshened. The rectum was repaired in two layers using 3-0 polyglactin running suture. Well-vascularized tissue was inserted between the repaired rectum and the urethra (16).
Study size was based on the number of patients with complete data for analysis identified through retrospective review. Descriptive statistics were used to describe demographic variables, assessments of urinary function, and post-operative complications. Missing data was excluded from analysis.
The mean follow-up period was 45.9 (range 12 to 131) months. There were no serious complications include severe infection and necrosis of the penile urethra in any patients during the immediate postoperative period. The penis was under the scrotum after the first procedure (Figure 3). According Male Urethral Stricture: AUA Guideline , the successful treatment is common defined as no further need for surgical intervention or instrumentation. The patients don’t experience obstructive voiding symptoms and peak uroflow >15 m/s (17). The procedure was successful in 19 patients (95%). The 19 patients voided well and mean urinary peak flow was 22.69 (range 15.7 to 31.4) mL/s. Urethral stricture developed in one patient (No. 9) and he had dysuria 6 months postoperatively, requiring interval dilatation once every 3 to 6 months. Interval dilatation was stopped 6 years later. Urinary peak flow was stabilized from 14 to 16 mL/s in the following 4 years. Eighteen patients had continence and one patient had stress incontinence postoperatively.
After 1 to 10 years of the procedure of transposition of the penis to the perineum with penile-prostatic anastomotic urethroplasty, nine patients underwent the second procedure of straightening the penis and repeat anterior urethral reconstruction. Of the nine patients, four underwent straightening the penis and one-stage anterior urethral reconstruction using a penile circular fasciocutaneous skin flap, five patients underwent straightening the penis and staged Johanson urethroplasty. Complications including an urethrocutaneous fistula and urethral stricture were developed in two patients, the other patients could void normally. In the remaining 11 patients, 10 had satisfactory results for voiding and were not willing to undergo any urethral reconstruction, and the last patient is a 16-year-old patient (No. 17) who voided well after the procedure, and was undecided whether to undergo the second procedure of straightening the penis and repeat anterior urethral reconstruction at present (Table 2).
The treatment of posttraumatic complex posterior urethral strictures in patients who have failed surgical intervention, and result in scrotal or bulbourethra to membranous urethral defects or strictures, is a very difficult surgical problem and is even more challenging than no scrotal or bulbourethra to membranous urethral defects or strictures to resolve. Numerous urethral reconstructive techniques have been described in the literature (8-15). There is, however, no universally accepted technique for either primary urethral reconstruction or salvage repair.
Enterourethroplasty has been reported for the treatment of complex posterior urethral lengthy defects or strictures (10-14). Bales et al. described a technique of urethral reconstruction using a tailored jejunal free tissue transfer to reconstruct the urethra in two patients with complex urethral strictures (11). Postoperatively, these patients had good urinary streams and were able to void in the standing position. However, the technique is time-consuming and surgeons must have experience with microvascular anastomosis. Sacculation of the neourethra may occur, which could result in post-void dribbling, infection, and stone formation. Lee et al. described the use of a reconﬁgured ﬂap of the sigmoid colon, much the same as described here but only 3 cm long, in one patient with a complicated pelvic fracture-related urethral injury who had a simultaneous sigmoid colocystoplasty and who did well after 15 months of follow up (12). Mundy et al. reported 11 patients with bulbomembranous urethral strictures or defects after trauma who were treated by interposition of a tailored intestinal ﬂap (13).
A penile circular fasciocutaneous skin flap has been frequently used for the treatment of anterior urethral strictures (6); however, if the blood supply of the flap is of poor quality, ischemic necrosis of the flap after urethroplasty and complications may occur. Perineo-scrotal skin is also frequently used for the treatment of long urethral strictures (9). Unfortunately, in these patients who underwent failed previous surgical treatments, there was not enough healthy perineoscrotal skin to be suitable for urethroplasty. In our group, four patients underwent second procedure of straightening the penis and one-stage anterior urethral reconstruction using a penile circular fasciocutaneous skin flap. Complications including an urethrocutaneous fistula and urethral stricture developed in two patients, in which there was a relationship with the poor blood supply.
In traumatic posterior urethral defects or strictures, the transperineal approach, excising the stricture and performing anastomotic urethroplasty is the gold standard treatment, and generally has a high success rate with the fewest complications (16-21). Surgical treatment of this disorder with perineal anastomotic urethroplasty was accompanied by a success rate of 82% to 95% in different studies. The key to achieving long-term successful outcome with this technique is dependent on two techniques: one is complete excision of the periurethral scar tissue. Flynn et al. reported a recurrence rate of 5% in 109 adults who underwent bulbo-prostatic anastomotic repair of a pelvic fracture with urethral distraction (21). The major cause of recurrent strictures was scar tissue around the urethra not having been excised completely during surgery, which resulted in postoperative scar contracture. We usually palpated the proximal end of the urethra and periurethral tissues after excising the urethral stricture, and excised the periurethral scar tissues until the surrounding tissues were soft (16,19,20). The other key technique was the tension-free end-to-end anastomosis. The routine anastomotic urethroplasty technique using a simple perineal approach was sometimes difficult for these patients with complex long-segment posterior urethral strictures (longer than 3 cm), because a tension-free end-to-end anastomosis was not sufficient to achieve long-term successful outcome. We usually adopted these techniques, including complete mobilization of the bulbar urethra, separation of the cavernous bodies, and inferior pubectomy to accomplish a tension-free bulbo-prostatic urethral anastomosis (16,19,20). However, it was very difficult to treat those patients with post-traumatic complex long-segment (longer than 6 cm) posterior urethral strictures who have undergone failed previous surgical treatments with these techniques. Routine techniques such as suprapubic cystostomy and urinary diversion can drain urine, but daily care post operation is troublesome, with risks of infection. Above all, patients prefer to be able to urinate autonomously. If the penis is transposed to the perineum, a tension-free penile-prostatic anastomotic urethroplasty is easily performed. In our group, 20 patients underwent the procedure of penis transposition to the perineum with penile-prostatic anastomotic urethroplasty, urethral stricture developed only in one patient postoperatively (No. 9). The dilatation was stopped 6 years later and urinary peak flow was stabilized from 14 to 16 mL/s during the following 4 years. The patient underwent again the second procedure of straightening the penis and one-stage anterior urethral reconstruction using a penile circular fasciocutaneous skin flap 10 years after the first procedure. However, a proximal anastomotic stenosis developed postoperatively and was managed by urethrotomy and interval dilatation.
Data on preoperative erectile function were available in all 20 patients. A total of 16 (80%) patients reported severe PED, 4 (20%) reported partial erections before admission. Preoperatively, patients were informed that the penis would be displaced under the scrotum post-operatively and that they would not be able to have normal sexual intercourse temporarily or permanently. If the patients voided well after the procedure and would consider undergoing the next second procedure of straightening the penis and repeat anterior urethral reconstruction, they were informed that complications such as urethral strictures and urethrocutaneous fistulas could occur. This technique should be applied that this can be added for severe, salvage, cases but not be regarded as a primary technique by any means and requires.
The treatment of the patient with posttraumatic complex posterior urethral strictures who have undergone failed previous surgical treatments was a very difficult surgical problem. Transposing the penis to the perineum with penile-prostatic anastomotic urethroplasty was an effective surgical salvage option for patients with posttraumatic complex posterior urethral strictures who have undergone failed previous surgical treatments and who have strictures or defects of the bulbo-menbranous urethra, especially older men with PED. This technique still requires more patients and more centers to verify reliability.
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at http://dx.doi.org/10.21037/tau-20-1024
Peer Review File: Available at http://dx.doi.org/10.21037/tau-20-1024
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tau-20-1024). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). When this technology was applied 18 years ago, our country didn’t have a complete Institutional Review Board (IRB) system. Therefore, the ethical approval is not required. Informed consent was obtained from the patients.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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