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Department of Urology
University of Washington | School of Medicine
Department of Urology
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Treatments & Procedures - Surgical

Urethroplasty

General Considerations

Retrograde urethrogram and voiding cystogram are performed prior to surgery to assess location and length of stricture. Cystoscopy is occasionally indicated for further characterization of the stricture (Figure 1). Prophylactic antibiotics are administered to cover gram negative organisms as well as the oropharyngeal flora in cases requiring grafts. General anesthesia is required due to positioning considerations

Bulbar Urethral Strictures

One Stage Free Graft Urethroplasty: Through a midline perineal incision, the corpus spongiosum is exposed by dividing the bulbospongiosus muscle (Figure 2). A self-retaining retractor greatly facilitates exposure. Using sharp dissection, the anterior surface of the corpus spongiosum is freed from the overlying muscle. Complete circumferential mobilization is not necessary for a ventral onlay technique, whereas this is required for dorsal onlay (Figure 3 and Figure 4).

The distal extent of the stricture is identified by gently passing a 20 Fr. catheter until it meets resistance. The corpus spongiosum is incised in the midline until the catheter tip and urethral lumen are exposed. The stricture is then incised along its entire length by extending the urethrotomy proximally. Once the entire stricture has been incised, the length and width of the remaining urethral plate are measured. Preservation of the urethral plate allows use of an onlay technique, which has superior outcomes when compared to full circumferential replacement of the urethra. Thus, if a portion of the stricture is extremely fibrotic or narrow, excision of that portion of the stricture and reanastomosis should be performed in conjunction with grafting. Proximal and distal calibration of the urethra with bougie-a-boules is critical to identify any residual narrowing. Cystoscopy is performed to inspect the bladder.

A buccal mucosa graft is then harvested (Figures 5, 6, 7, 8). For buccal grafts, a 6-cm segment can be taken from each inner cheek. The graft is dissected off of the buccinator muscle with scissors and placed in saline. Any bleeding points are cauterized. The defect is closed primarily with running or interrupted 3-0 chromic suture and a sponge placed in the mouth until the end of the case.

Graft take depends on the ability of the graft to imbibe nutrients for 24 to 48 hours until inosculation by the neovasculature from the graft bed takes place. Thus all fat and muscle needs to be meticulously removed from the graft. A silicone block and 28 gauge needles are used to stretch out the graft and allow complete defatting.

The graft is trimmed to its appropriate size. A urethral lumen of 30 Fr. is desirable, and thus in general we use a 2 - cm wide graft. One end of the graft is anastomosed to the proximal apex of the urethrotomy and 6-zero absorbable suture is used to complete a watertight anastomosis along each side of the graft. Tacking sutures of chromic may be used to lay the graft into position prior to anastomosis. The proximal lumen is calibrated with bougies to ensure an adequate lumen and a 16 Fr urethral catheter is placed prior to closing the distal portion of the urethra. The bulbospongiosus muscle is reapproximated and Colles' fascia and the skin are closed with interrupted absorbable sutures. Fluff dressings and an athletic supporter dress the wound.

Postoperative Care: Patients may resume a regular diet by the next morning and can be discharged within 24 hours. A voiding cystourethrogram is performed at 2 weeks in conjunction with catheter removal. Standard followup includes cystoscopy at 3 months and 1 year.

Successful voiding without recurrence of stricture is achieved in 85% of cases. Recurrent strictures often respond to minimally invasive procedures and rarely require reoperation.

Distal Urethral Strictures

Two Stage Urethroplasty is reserved for strictures with complete obliteration of the urethral lumen and a location typically on the distal pendulous portion of the penis (Figure 9). First, we perform primary excision of the strictured urethra through a midline ventral penile skin incision, extending out to the head of the penis if the urethral meatus is involved. The first stage urethroplasty uses full thickness grafts harvested from the oral cavity to cover the defect resulting from removal of the diseased urethra. Each graft is defatted and fenestrated with an 18 g needle. The grafts were sutured to the tunica albuginea and a proximal urethrostomy is formed. Non-abrasive bolster dressings are placed on the urethroplasty for 3 to 5 days, during which time the patient remains hospitalized. A catheter is left in place for 10 days.

The second stage procedure is performed 9 months later (Figure 10). Some men elect not to proceed to second stage. For the 2nd stage, surgery is less complex. A 2 hour procedure allows grafts to be tubularized over a catheter. Any urethral stricture recurrences prior to tubularization are excised and regrafted. This procedure requires an overnight hospitalization and 10 days catheterization.

Overall a 75% long term successful outcome can be expected. Complications include graft loss (5%), fistula formation (5%) and recurrent stricture (20%).

Posterior Urethral Traumatic Injuries

One Stage Posterior Urethroplasty: Surgical reconstruction is performed 3 to 6 months post injury, once the acute damage has subsided and been replaced by scar (Figure 11). The approach is via midline perineal incision with the patient in the exaggerated lithotomy position (Figure 12). After circumferential mobilization and transection of the bulbar urethra, fibrotic tissue from the obliterated membranous urethra is excised until a healthy, compliant prostatic apex is defined (Figure 13). The bulbar urethra is dissected distally to gain length and allow tension free reanastomosis of the bulbar urethra to the prostatic apex. Additional maneuvers include division of the corporal bodies (Figure 14), inferior pubectomy, and total pubectomy (Figure 15). Bulboprostatic anastomosis is performed using 12 interrupted sutures of 5-zero maxon, and urethral and suprapubic catheter drainage was maintained.

Postoperative Care: Patients remain hospitalized for 24 hours and require catheter drainage for three weeks. Followup x ray studies involve voiding cystourethrography (Figure 16). The catheter is removed and voiding is attempted. If persistent extravasation was noted on xray, the suprapubic catheter was left to gravity drainage until repeat studies are normal. Standard followup includes cystoscopy at 3 months and 1 year.

Over 90% of patients with posterior urethral rupture maintain urethral patency at 5 to 10 years post surgery.

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