V12-07: Reconstruction of a sixteen-centimeter anterior urethral stricture: Double dorsal buccal mucosa graft with the Asopa technique
Video
INTRODUCTION
Multiple surgical techniques have been described for long segment anterior urethral strictures (LSAUS), including staged urethroplasty, dorsal buccal mucosa graft (DBMG), fasciocutaneous flap, perineal urethrostomy and flap plus graft. In 2001 Asopa et al. described a new technique for dorsal graft by exposing the stricture through a ventral urethrotomy and a wide midline incision of the urethral plate to acommodate the dorsal graft. Compared to DBMG a randomized study showed significantly less blood loss and less operative time for Asopa technique with a similar 2-year success rate over 85%. Theoretically, in this approach blood supply is better preserved. In addition, it has been claimed that it is easier to learn and may provide a better visualization of the diseased urethra._x000D_ The aim of this video is to provide a detailed demonstration of the Asopa technique to solve a LSAUS which required a double sequential BMG graft
METHODS
A 60 year-old patient with long-standing lower urinary tract symptoms presented with acute urinary retention; urethral catheterization was impossible and a suprapubic cystostomy was placed. Urethrocystoscopy and retrograde urethrogram confirmed a LSAUS, with severe spongiofibrosis._x000D_ Surgical Technique: A vertical perineal incision and midline splitting of the bulbospongiosum muscle allow for wide exposure of the corpus spongiosum. Urethroscopy was used to determine the distal end of spongiofibrosis. Then, a ventral urethrotomy along penile and bulbar urethra is performed until healthy urethra is found. A deep midline dorsal urethrotomy is done dissecting urethral plate with an ophthalmic scalpel in order to accommodate a double tandem BMG affixed to the underlying corpus cavernosum with absorbable running sutures. Interrupted stitches are placed in the midline to facilitate graft take. A 16F urethral catheter is placed and standard closure by layers is performed using running sutures_x000D_
RESULTS
Operative time was 173 minutes and blood loss was 200cc. Total stricture length was 16 cm. Patient was discharged on the 4th postoperative day with a suprapubic tube and a silicone urethral catheter. There were no postoperative complications. Pericatheter retrograde urethrogram at 3 weeks showed minimal extravasation so urethral catheter was removed. Cystostomy was left one more week and then removed. Six months after surgery his AUA-IPSS questionnaire was 5 and Qmax was 17 ml/sec
CONCLUSION
For LSAUS, the Asopa technique appears to be a reproducible, safe and effective choice to be considered in these complex cases
Funding: none