V12-08: Single-stage urethroplasty with complete retubularisation of oral grafts for distal penile strictures.
Distal penile strictures, most of them related to lichen sclerosis (LS) or failed hypospadias surgery, often require circumferential substitution after excision of the scarred urethra. These are usually treated by a staged approach, excising the spongiofibrosis and creating a neo-urethral plate using oral mucosa (OM), and retubularising it 3 to 6 months later. In selected cases, these two steps can be performed in a single stage. This video demonstates this two-in-one staged approach for distal penile urethroplasty and reports the outcome in a series of patients.
A 48 year old man developed a recurrent distal penile urethral stricture after reconstructive surgery for hypospadias in childhood. There is a hypospadic meatus at the level of the corona and extensive LS involvement of the glans and foreskin. A ventral stricturotomy is performed. All the scarred tissue is excised and the glans cleft is deepened to develop the glans wings and fashion a neo-meatus at the tip. OM is harvested from the left cheek in this case and quilted dorsally to create a neo-urethal plate with an adequate calibre. At this point, after careful intraoperative evaluation, if the quality of the tissues – including spongiosum, dartos and glans size – is adequate to support the graft and allow retubularisation, the neo-urethra is closed in layers over a 20F sound. _x000D_ Between 2007 and 2013, 212 penile urethroplasties were performed in a single unit. 40 of these were using the technique described. Patients were followed up objectively and subjectively for a mean of 16.2 months (6-63 months)._x000D_
The stricture aetiology was LS in 22 (55%) and hypospadias in 13 (32.5%). The other 5 (12.5%) were iatrogenic trauma. Strictures were mostly localised to the navicular fossa (n=20; 50%) and distal penile urethra (n=16; 40%). 40% (n=16) were redo-procedures after prior failed urethroplasty. Mean stricture length was 3.5cm (range 1.3-8cm). 36 patients (90%) had a successful outcome, 2 patients developed recurrent stricture and 2 cases were complicated by urethro-cutaneous fistulae, requiring further surgical repair.
A “two-in-one” urethroplasty using OM for complete urethral substitution is a suitable option for selected penile urethral strictures, after careful intraoperative assessment of the stricture. An excellent outcome is achievable in high volume centres. Advantages include improved patient satisfaction associated with fewer surgical interventions and avoidance of a proximal urethrostomy in the interim between the two stages.