V12-12: Two-stage Urethroplasty with Prefabricated Gracilis-Buccal Mucosa Composite Flap

Video

Introductions and Objectives
In patients with devastated bulbous urethra (i.e. spongionecrosis, failed skin tube repairs, watering can perineum) repair options include buccal mucosa-dartos composit flap, enterourethroplasty, perineal urethrostomy or diversions._x000D_ Here we demonstrate a novel technique to reconstruct a devastated bulbous urethra. This 2-stage technique involves creation of two independently vascularized urethral hemi-plates lined with buccal mucosa (BMG). In the first stage the dorsal plate is created by quilting BMG onto corpora cavernosa and the future ventral plate is grafted onto exposed distal gracilis muscle. During the second stage the two fabricated plates are anastomosed by bringing gracilis into perineum. To our knowledge this is the first report of reconstructing entire segment of devastated urethra in such manner.

Methods
A 57 year old male with prior urethroplasty had a new penetrating injury to perineum. He presented with perineal abscess and fistula, underwent incision and drainage and suprapubic tube placement. Three months later he presented for reconstruction. In the stage 1 the affected urethra is dissected and removed leading to a 5cm defect. Two 6x2.5 cm BMG harvested, defatted and fenestrated. One graft was quilted on corpora cavernosa and anastomosed to the spatulated urethral stumps. Perineal urethrostomy was created by approximating edges of skin to the edges of urethral plate. A catheter is placed in the urethrostomy and a tie-over dressing applied. Next, Gracilis tendon is identified. A 6-cm skin defect was created and muscle sutured to the skin edges. The second BMG was quilted on the muscle and a tie-over dressing applied._x000D_ 8 weeks later, stage 2, the gracilis-BMG composite is harvested. The muscle is passed into the perineal incision and the BMG edges on the flap are anastomosed the edges of the dorsal graft. The gracilis muscle is sutured to corpora cavernosa.

Results
Patient underwent a 2-stage repair w/o complications and was sent home on day 1 each time. VCUG demonstrated patent urethra with reconstructed bulbous fragment similar to native urethra. Maximum uroflow was 18 cc/sec.

Conclusions
We demonstratedthe feasibility of using prefabricated BMG- gracilis composite flap for repair of devastated urethra. This technique avoids use of hair-bearing skin or GI segments. Gracilis muscle provides vascular bed ventrally and reduces the risk of developing ventral diverticulum. Independently vascularized urethral hemi-plates require minimal dissection to achieve tension-free anastomosis. Additional two patients are awaiting the second stage of this operation.

Funding: none