V2-06: Reconstruction of the strictures of fossa navicularis and urethral meatus by using transverse island fasciocutaneous penile flap (TIFP) with the glans cap technique

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Introductions and Objectives
Urethral strictures involving the fossa navicularis and external meatus require the reconstruction of both a functional and a cosmetic outlet. We describe our experience with ventral TIFP in the management of distal urethral strictures.

Methods
Between 1997 and 2012, 46 men (mean age: 54 years) with distal urethral strictures confined to the fossa navicularis and urethral meatus underwent ventral TIFP urethroplasty with the glans cap technique. The etiology of the stricture was iatrogenic in 40 (transurethral resection of the prostate or bladder tumor) and inflammatory/idiopathic in 6. All except 4 patients had undergone multiple previous urethral dilatations. Preoperative evaluation included uroflowmetry with residual urine volume determination, retrograde urethrography (RU) and voiding cystourethrography (VCUG), and urethrocystoscopy with a pediatric ureterorenoscope. During surgery, a subcoronal incision was made on the ventral penile skin and carried down through Buck’s fascia until the urethra. Fossa navicularis and meatus were exposed by dissecting the urethra under the glans. The strictured urethra was then incised ventrally, including the meatus. A ventral fasciocutaneous island flap was mobilized and anastomosed to the edges of the urethral incision, augmenting the urethra to admit a 24-26F sound without difficulty. Urethral catheter was removed after 2 weeks. Patients were followed for obstructive symptoms and 3 monthly uroflowmetric studies in the first year and annually thereafter. Cure was defined as patient satisfaction and the absence of any restenosis requiring additional intervention.

Results
Stricture length ranged between 7 to 25 mm. Mean operation time was 50 min. Flap necrosis developed in one patient with subsequent fistula formation. Cure was achieved in 43 (93.4%) men at a mean follow-up of 78 months (range: 3-144). The procedure failed in 2 patients due to lichen sclerosus, which was diagnosed after the recurrence and managed with a 2-stage buccal mucosa graft urethroplasty. The mean Qmax was increased from 7.2 ml/sec preoperatively to 19.4 ml/sec at the last follow-up visit (p=0.001, Wilcoxon sign test).

Conclusions
TIFP is an effective technique for the reconstruction of urethral strictures involving the fossa navicularis and external meatus. It restores a functional and cosmetic outcome with preservation of the glandular integrity. Inflammatory genital skin diseases must be carefully evaluated before surgery to achieve optimum success with this technique.

Funding: none