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CASE REPORT
Year : 2020  |  Volume : 47  |  Issue : 1  |  Page : 37-40

Augmented anastomotic urethroplasty with ventrally placed buccal mucosal graft


Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Belagavi, Karnataka, India

Date of Submission30-Jan-2020
Date of Acceptance20-Mar-2020
Date of Web Publication23-Jun-2020

Correspondence Address:
Dr. R B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_6_20

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  Abstract 


The most common site of anterior urethral stricture is the bulbar urethra. The etiology of these strictures could be either idiopathic (40%), iatrogenic (35%), inflammatory (10%), or traumatic (15%) causes. Several techniques and approaches with/without buccal mucosal graft have been described. We report a modification to the standard anastomotic urethroplasty, wherein following excision of a 2.0-cm bulbar urethral stricture, we performed a roof strip anastomosis followed by ventral buccal mucosal augmentation urethroplasty.

Keywords: Bulbous urethral stricture, surgical anastomosis, urethra, urethroplasty


How to cite this article:
Nerli R B, Deole S, Devraju S, Ghagane SC, Hiremath MB, Dixit NS. Augmented anastomotic urethroplasty with ventrally placed buccal mucosal graft. J Sci Soc 2020;47:37-40

How to cite this URL:
Nerli R B, Deole S, Devraju S, Ghagane SC, Hiremath MB, Dixit NS. Augmented anastomotic urethroplasty with ventrally placed buccal mucosal graft. J Sci Soc [serial online] 2020 [cited 2020 Jul 11];47:37-40. Available from: http://www.jscisociety.com/text.asp?2020/47/1/37/287494




  Introduction Top


The most common site of anterior urethral stricture is the bulbar urethra.[1] About 40% of the bulbar urethral strictures are idiopathic, particularly so in the developed world. Some of these idiopathic urethral strictures could be of congenital origin. Nearly a third of all bulbar urethral strictures are reported following urethral instrumentation, including surgery for hypospadias, and the rest have a history of infection, especially history of sexually transmitted diseases.[2],[3] Several surgical techniques and approaches with or without the use of buccal mucosal graft (BMG) have been reported for the management of bulbar urethral strictures including dorsal onlay,[4] ventral onlay,[5] Asopa dorsal inlay,[6] double face with BMG, and nontransaction anastomotic urethroplasty, in addition to end-to-end anastomosis.[7] Several controversies surround the current practices of bulbar urethral surgery including the use of buccal mucosa, grafting versus anastomotic repair, and the use of dorsal versus ventral placement of the graft and surgical options for patients with failed hypospadias repair.[8] Each and every technique of repair has its own advantages.

The main indications for an end-to-end bulbar anastomotic urethroplasty include a traumatic stricture or a redo surgery with excessive scar tissue in the corpus spongiosum. Currently, primary end-to-end anastomosis is indicated for the repair of a 1–2-cm-long bulbar urethral stricture. Many authors[9] strongly believe in avoiding transection of the urethra unless necessary and are based on the sound reasoning of maintaining the bulbar urethral arterial supply. Transecting the urethra may lead to vascular and neurogenic damage to the urethra and penis and may promote postoperative erectile dysfunction. Traumatic strictures are invariably associated with extensive spongiofibrosis, and therefore, one needs to transect the urethra so as to clear the scarred and fibrotic tissue.[10] Moreover, due to poor blood flow across the corpus spongiosum, there is a clear zone of tissue wasting in cases of traumatic stricture. One should reserve anastomotic urethroplasty only in cases of traumatic strictures and failed cases with extensive inflammation and scarring.

We report a modification to the standard anastomotic urethroplasty, wherein following excision of a 2.0-cm bulbar urethral stricture, we performed a roof strip anastomosis followed by ventral buccal mucosal augmentation urethroplasty.


  Case Report Top


A 76-year-old male presented to the urological services of the hospital with retention of urine. Following failure to pass a urethral catheter, a suprapubic cystostomy was done and the bladder was drained continuously. A retrograde urethrogram was done, which revealed abrupt complete blockage at the level of the proximal bulbar urethra. A voiding cystourethrogram was attempted, but the proximal urethra could not have delineated. A bougie urethrogram was done [Figure 1], which revealed a bulbar urethral stricture of approximately 2.0 cm in length. The patient was planned for excision of the stricture followed by anastomotic urethroplasty.
Figure 1: Bougie urethrogram showing a 2-cm-long bulbar urethral stricture

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Surgical technique

Following general anesthesia, the patient was positioned in a modified lithotomy position with thromboembolic deterrent stockings. The skin was prepared from the umbilicus down to the mid-thigh and the patient draped to expose the perineum and the suprapubic area around the suprapubic catheter site. Prophylactic antibiotics were given intravenously along with anesthesia.

A midline perineal incision [Figure 2]a nearly 8–10 cm long was made along the line of the raphe, almost to the anal margin. The incision was deepened through the subcutaneous tissue, Colles' fascia, and onto the bulbospongiosus muscle in the center of the wound, exposing the urethra itself, distal to bulbospongiosus, in the upper part of the wound and the subcutaneous part of the external anal sphincter in the lower part of the wound. The bulbospongiosus muscle was then carefully reflected off the bulbar urethra and retracted out of the way. This freed the ventral aspect of the urethra back to the perineal body. The proximal bulbar urethra was then separated posteriorly from the perineal body by sharp dissection, all the way up to the membranous urethra. It was then separated dorsally from the tunica albuginea of the penis by dividing Buck's fascia on either side of the urethra. The bulbar urethra was completely free from the penobulbar junction, all the way up the membranous urethra. The remaining posterolateral attachments were the points where
Figure 2: (a) Midline perineal incision. (b) The urethra was transected through the site of obliteration. (c) The proximal and distal ends were trimmed back to healthy tissue. (d) The proximal urethral end

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the bulbar arteries run into the corpus spongiosum on either side. Whenever bulbar anastomotic urethroplasty is being done these are left alone.

A 20 Fr catheter was then passed down the urethra to the site of the obstruction. The ventral aspect of the urethra appeared atrophic with severe scarring. The urethra was then transected through the site of obliteration, trimmed back to healthy tissue on either side [Figure 2]b, [Figure 2]c, [Figure 2]d. Cystoscopy from the transected end of the proximal urethra showed normal caliber and normal mucosa [Figure 3]a. The urethra on the distal side was spatulated [Figure 3]b. The bulbar urethra on the proximal side too was refreshed, and unhealthy scarred tissue was excised. This left a huge gap on the ventral aspect of the urethra. In spite of adequate mobilization, the two ends of the urethra could be approximated without tension only on the dorsal aspect (roof strip) [Figure 3]c. The strip of the urethra (5–8 mm) on the dorsal aspect was approximated using 5/0 absorbable sutures so as to complete the dorsal hemi-circumference of the urethra. A huge 2–3-cm gap was seen on the ventral aspect of the urethra. An 18 Fr silicone catheter was passed across the two ends of the urethra into the bladder. It was decided to suture and close the ventral urethra with a BMG.
Figure 3: (a) Cystoscopic appearance of a proximal urethra. (b) Sutures taken on the dorsal aspect of both the proximal and the distal urethras. (c) Roof strip anastomosis done. (d) The ventral gap was completed using a 3-cm buccal mucosal graft

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A 3-cm-long BMG was extracted from the patient's right cheek. This graft was placed ventrally and sutured to the urethral margin using 5/0 polyglactin sutures [Figure 3]d and [Figure 4]a, [Figure 4]b. The bulbospongiosus muscle was approximated over the urethra. The wound was closed in layers and dressed.
Figure 4: (a) An 18 Fr silicone catheter inserted into the urethra. (b) Augmented anastomotic urethroplasty performed ventrally

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The postoperative period was uneventful. The suprapubic catheter was removed on the 7th postoperative day and the periurethral catheter removed on the 12 postoperative days. The patient voided with a maximum flow of 18.2 mL/s. The patient has been followed up over a period of 6 months, and the patient has no complaints regarding urinary flow, perineal wound, and postvoid dribbling.


  Discussion Top


There are various ways and techniques to perform a bulbar urethroplasty, and it is noteworthy that no technique or procedure scores over the rest. A reconstructive surgeon must be familiar with the use of various surgical techniques so as to manage any condition of the urethra that might emerge at the time of urethroplasty. Several variables such as length, severity and location of stricture do influence the choice of the procedure and so does the surgical outcome. The surgical technique should be selected depending on the length of the stricture, etiology of the stricture, and the density of spongiofibrosis.

Short bulbar strictures are generally amenable to complete excision with primary anastomosis through a perineal incision, affording a high success rate of 95%, as reported by several authors.[11],[12] Eltahawy et al.[12] published their series of 260 patients with bulbar stricture who underwent end-to-end anastomosis with a mean follow-up of 50.2 months. The stricture length ranged from 0.5 cm to 4.5 cm (mean, 1.9 cm), and the authors reported a success rate of 98.8%. Barbagli et al.[13] too described a success rate of 90.8% in 153 patients who underwent bulbar end-to-end anastomosis with a mean follow-up of 68 months.

Complete excision of abnormal urethral mucosa and spongiofibrosis and tension-free anastomosis is important for achieving the good results. The ideal stricture length for excision and end-to-end anastomosis has been a contentious issue. Guralnick and Webster[14] insisted that this operation should be limited to strictures of 1 cm or less because excision of a 1-cm urethral segment with opposing 1-cm proximal and distal spatulations results in a 2-cm urethral shortening. They emphasized that excision of a longer urethral segment risks penile shortening or chordee.[14]

The main indication of augmented anastomotic urethroplasty in end-to-end anastomosis is when there is a loss of urethral tissue or length which could cause further shortening of the bulbar urethra and lead to chordee. If transecting normal tissue leaves a large gap, then this gap could be augmented with BMG. The spongious tissue on the ventral aspect is more elastic and usually could accommodate the gap easily. The ventral aspect of the urethra is slightly longer than the dorsal aspect. Hence, it is usually recommended to insert the BMG dorsally. In our case, the urethral tissue on the ventral side was short that left the gap ventrally. In our case, we inserted the BMG on the ventral aspect. This could be an option when excision leads to a gap on the ventral aspect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hampson LA, McAninch JW, Breyer BN. Male urethral strictures and their management. Nat Rev Urol 2014;11:43-50.  Back to cited text no. 1
    
2.
Mundy AR, Andrich DE. Urethral strictures. BJU Int 2011;107:6-26.  Back to cited text no. 2
    
3.
Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol 2008;54:1031-41.  Back to cited text no. 3
    
4.
Barbagli G, Selli C, di Cello V, Mottola A. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. Br J Urol 1996;78:929-32.  Back to cited text no. 4
    
5.
Morey AF, McAninch JW. When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology 1996;48:194-8.  Back to cited text no. 5
    
6.
Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology 2001;58:657-9.  Back to cited text no. 6
    
7.
Andrich DE, Mundy AR. Non-transecting anastomotic bulbar urethroplasty: A preliminary report. BJU Int 2012;109:1090-4.  Back to cited text no. 7
    
8.
Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M. Current controversies in reconstructive surgery of the anterior urethra: A clinical overview. BJU Int 2012;38:307-16.  Back to cited text no. 8
    
9.
Joshi P, Kaya C, Kulkarni S. Approach to bulbar urethral strictures: Which technique and when? Turk J Urol 2016;42:53-9.  Back to cited text no. 9
    
10.
Nerli RB, Koura AC, Ravish IR, Amarkhed SS, Prabha V, Alur SB. Posterior urethral injury in male children: Long-term follow up. J Pediatr Urol 2008;4:154-9.  Back to cited text no. 10
    
11.
Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: Analysis of 168 patients. J Urol 2002;167:1715-9.  Back to cited text no. 11
    
12.
Eltahawy EA, Virasoro R, Schlossberg SM, McCammon KA, Jordan GH. Long-term follow-up for excision and primary anastomosis for anterior urethral strictures. J Urol 2007;177:1803-6.  Back to cited text no. 12
    
13.
Barbagli G, De Angelis M, Romano G, Lazzeri M. Long-term follow-up of bulbar end-to-end anastomosis: A retrospective analysis of 153 patients in a single center experience. J Urol 2007;178:2470-3.  Back to cited text no. 13
    
14.
Guralnick ML, Webster GD. The augmented anastomotic urethroplasty: Indications and outcome in 29 patients. J Urol 2001;165:1496-501.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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