Vol. 118, September

THE JOURNAL OF UROLOGY

Printed in U.SA.

Copyright © 1977 by The Williams & Wilkins Co.

TWO-STAGE URETHROPLASTY FOR URETHRAL STRICTURE DISEASE ALAN J. WEIN, JOSEPH V. LEONI, THOMAS C. SANSONE, S. GRANT MULHOLLAND AND MORTON BOGASH From the Division of Urology, Department of Surgery, University of Pennsylvania School of Medicine and the Veterans Administration Hospital, Philadelphia, Pennsylvania

ABSTRACT

Of 97 patients who underwent first-stage urethroplasty 23 per cent required at least 1 revision. Sixty-seven patients underwent second-stage reconstruction with a 90 per cent success rate. The various factors influencing the outcome of2-stage urethroplasty procedures are analyzed critically. RESULTS

The various types of 2-stage urethroplasty currently in use have the same basic principles. In the first stage the strictured area of the urethra is opened and enlarged by marsupialization to the skin. The numerous approaches differ only in the type of skin used and in the way in which the skin is approximated to and around the opened urethra. Johanson first described the 2-stage approach for the repair of anterior and posterior urethral strictures. 1 He used an inverted funnel of scrotal skin to complete the first-stage repair of posterior strictures. Lapides, 2 Turner-Warwick, 3 • 4 Stewart,5 Leadbetter, 6 Gil-Vernet,7 and Blandy and associates8 • 9 described useful modifications of this first-stage procedure for deeper strictures, the most popular of which involve a buttonholed scrotal inlay flap,3· 4 an inverted U-shaped perineal skin flap 6 and an inverted U-shaped scrotal skin flap. 8 • 9 In the second stage of the repair the urethra is reconstructed to a normal caliber by using the buried skin strip approach of Denis Browne 1• 2 • 6• 10-12 or by creating a new epithelial tube in the marsupialized area. 3 • 4 • 7-s, 13 Herein we describe our results with 2-stage urethroplasty procedures and compare them to those in the literature.

Sixty-seven patients (69 per cent) underwent both stages of the 2-stage urethroplasty. Thirty patients (31 per cent) underwent only the first-stage repair (table 3). First-stage procedures. Of the 15 first-stage repairs of penile strictures all but 1, which required a single revision of the distal stoma, were initially successful (table 4). Of the 82 firststage procedures done for bulbomembranous disease all were ultimately successful but 21 required 1 or more revisions (tables 4 and 5). Of the scrotal flap repairs 83 per cent (20 of 24) were initially successful compared to 71 per cent (41 of 58) of repairs using a perineal skin flap. Second-stage procedures. The criteria for success of a second-stage urethroplasty procedure were that 1) no subsequent urethral dilation was required, 2) no fistula occurred and 3) voiding occurred with a forceful stream and without subjective complaints. By these criteria there were 60 successes and 7 failures (table 6). The failures consisted of 3 fistulas-all with buried strip repairs, 3 strictures-2 of which occurred with buried strip repairs and 1 case of a fistula and a stricture, which occurred after a tube-type repair. Over-all, there was little difference in the success rates of the 2 types of repair, although the tube-type repair was slightly more successful in the bulbomembranous area (table 6). Forty-four of the 67 patients (66 per cent) had persistent or recurrent urinary tract infection after the second-stage repair. In this subgroup a successful outcome occurred in 38 patients (86 per cent). Of the 23 patients who had no long-term problem with infection only 1 man (with a penoscrotal junction stricture) had an unsuccessful second-stage repair (table 7). Six patients whose repairs extended to the area of the verumontanum underwent a transurethral prostatectomy either before the urethroplasty (3 patients) or after it (3 patients). Only 1 of them, who had had a prior resection, was incontinent after the urethroplasty. Hair stones were noted in 10 of 22 patients (45 per cent) who underwent cystoscopy 5 or more years after the second-stage repair. Marked urethral irregularity (see figure) was seen in 9 of 47 patients (19 per cent) who had retrograde urethrograms 5 or more years after urethroplasty but they were considered successes (albeit qualified ones) since postoperative urethral manipulation was unnecessary in these cases.

METHODS

Adequate followup data were obtained on 97 of 120 patients who underwent urethroplasty between 1964 and 1974. At operation the patients ranged in age from 9 to 85 years, with a median age of 53 years. Fifty-two patients (54 per cent) had strictures resulting from infection, primarily gonorrheal. The second most common cause (26 patients, 27 per cent) was instrumentation or catheterization, or both. There were only 11 cases (11 per cent) of stricture secondary to external trauma. Seven strictures (7 per cent) were of unknown etiology and 1 was secondary to cancer. Of the primary factors motivating the urethroplasty (table 1) only secondary fistula and abscess formation were considered absolute indications. The strictures were predominantly bulbomembranous in location (table 2). All but 2 penile strictures were located at the penoscrotal junction. Preoperatively, 72 per cent of the patients had had urinary tract infection. The majority of infections were chronic and of long duration. The causative organisms included Proteus (33 per cent), Escherichia coli (28 per cent), Pseudomonas (22 per cent) and Klebsiella-Enterobacter (17 per cent). A perineal6 or a scrotal flap 8 • 9 was used in the first-stage repairs involved the Lapides modification of the buried strip technique2 or the creation of a new epithelial tube, as described by Blandy and associates. 8 • 9

COMMENT

Meaningful comparisons between various series of urethroplasties are hindered by the number of variables involved, including: 1) the surgical technique used, 2) the type, duration and severity of the stricture disease, 3) the presence or absence of infection, abscess or fistula, 4) the type of patient population and 5) whether the final success rate is dependent on the surgical correction of 1 or more complications. Most authors report a final success rate between 86 and 100

Accepted for publication November 24, 1976. Read at annual meeting of Mid-Atlantic Section, American Urological Association, Dorado Beach, Puerto Rico, September 26-0ctober 1, 1976. 392

TWO-STAGE URETHROPLASTY TABLE

393

1. Primary factors motivating urethroplasty No. Pts.

Episodes of retention and/or impassable stricture Multiple or difficult dilations or dilation sequelae Fistula and/or abscess Rectal cancer invading urethra

TABLE

16 46

34 l

2. Location of stricture No.

Penile Bulbomembranous: Bulbar Membranous Bulbar and penile TABLE

(%)

15 72 58 14

(16) (74) (60) (14)

10

(10)

3. Reasons for not doing second-stage procedure No. Pts.

Age and/or patient desire Still awaiting second-stage procedure Metastatic cancer Atonic bladder

19 5

5

1

Total

30

TABLE

4. First-stage urethroplasty: success rates Penile No.

Success after 1 operation Success after 2 operations Success after 3 operations TABLE

14 1

Bulbomembranous No.

(%)

(%)

(93)

61

(74)

(7)

19

(23)

2

(2)

0

5. Revisions of first-stage bulbomembranous repairs Type of Revision

No. Pts.

Proximal Distal Proximal and distal Operation for bridging 2 proximal 2 proximal and 2 distal TABLE

12 3 2 2 l 1

6. Second-stage urethroplasty: success rates Type of Repair Tube

Strip

Total

--------------------No. (%) No. (%) No. (%)

Successful Penile Bulbomembranous Totals TABLE

Successful

Successful

4/5 17/18

(80) (94)

5/6 34/38

(83) (89)

9/11

(82)

51/56

(91)

21/23

(91)

39/44

(89)

60/67

(90)

7. Success rates and incidence of chronic or recurrent postoperative urinary infection

Penile Bulbomembranous Totals

Infection

No Infection

No. (%) Successful

No. (%) Successful

6/7 32/37

(86) (86)

3/4 19/19

(75) (100)

38/44

(86)

22/23

(96)

per cent with a 2-stage repair consisting of a perineal flap or scrotal flap procedure followed by a Denis Browne, modified Denis Browne or tube reconstruction procedure. 6 • 9 , 14-16 Similar success rates have been reported with the Turner-Warwick scrotal inlay procedure. 3 • 4 • 14• 1 H 9 Interval operations (not including depilation) between first and second-stage procedures appear to have been necessary in 10 to 44 per cent of cases, regardless of the type of first-stage repair done. 9• 14-19 In our experience the use of a scrotal flap for the first-stage repair of a bulbomembranous stricture had a better initial

Postoperative retrograde urethrogram shows markedly irregular but widely patent urethra with pseudodiverticulum.

success rate (83 per cent) than did a similar procedure using a perineal flap (71 per cent). A scrotal, rather than perineal, skin flap procedure does seem to present fewer technical difficulties and possesses some practical advantages. However, many of our initial failures with the perineal flap procedure occurred early in the series, when proportionally more patients presented with an abscess, fistula and/or a more severe type of longstanding stricture disease. We expected a higher second-stage success rate with the tube technique than with the buried strip technique. Although the tube technique did result in a slightly better repair of deep strictures there was essentially no over-all difference. We now prefer to divert our tube-type second-stage urethroplasties by suprapubic cystotomy, rather than by a Foley catheter, because the cystotomy diversion decreases the risk of urethritis and allows for an antegrade urethrogram to preclude extravasation at the repair site prior to the resumption of normal voiding. Although the success rate for suprapubic drainage with a second-stage bulbomembranous tube repair did exceed that of Foley catheter drainage (8 of 8 versus 9 of 10), the l penile failure using a tube-type repair occurred with suprapubic drainage, leaving this bias open to question. Persistent recurrent infection after urethroplasty does seem to affect the success rate adversely. It is possible that such infection occurs only in association with the most severely damaged urethras. Nevertheless, a vigorous attempt to eradicate infection and maintain urinary antisepsis should be made. The incontinence rate after transmembranous urethroplasty preceded or followed by a closed or open prostatectomy has been, in various series, 4, 16 1220 and 20 per cent. 21 Certainly, anyone with transient incontinence after 1 procedure is at greater risk after a second procedure. ff a transurethral prostatectomy is done after transmembranous urethroplasty a more conservative resection of apical tissue than usual is recommended. Our definition of a successful 2-stage urethroplasty refers only to the adequacy of voiding and to the absence of the need for postoperative urethral dilation. Clearly, many patients satisfy these criteria who, nevertheless, prove to have persistent infection, hair stones or irregular urethras on close inves .. tigation. We did not routinely depilate our first-stage and many cases of chronic postoperative infection may been related to a hair nidus. In our experience the more closely patients who have undergone second-stage urethro-

394

WEIN AND ASSOCIATES

plasty are investigated on a long-term basis the greater the likelihood of finding a condition that places the result in the qualified success category. Currently reported success rates for a 1-stage urethroplasty using a patch or tube graft of free, full-thickness skin range as high as 84 to 93 per cent. 22 • 23 A variation of this 1-stage procedure, using a pedicled, full-thickness island of skin, has yielded a success rate of 96 per cent. 24 Consistently high success rates such as these with strictures of all types and degrees of severity suggest that such a 1-stage operation may eventually become the procedure of choice for most patients, the exceptions being those who present with an abscess or fistula, or with severe infection. Finally, on the basis of our observations of the 30 patients whose first-stage urethroplasty was not followed by a secondstage procedure, we agree with Thompson and associates 25 that there are many instances in which a well functioning first-stage urethroplasty in a satisfied patient represents an optimal result. REFERENCES

1. Johanson, B.: Reconstruction of the male urethra in strictures. Acta Chir. Scand., suppl. 176, p. 3, 1953. 2. Lapides, J.: Simplified modification of Johanson urethroplasty for strictures of deep bulbous urethra. J. Urol., 82: 115, 1959. 3. Turner-Warwick, R. T.: A technique for posterior urethroplasty. J. Urol., 83: 416, 1960. 4. Turner-Warwick, R.: The repair of urethral strictures in the region of the membranous urethra. J. Urol., 100: 303, 1968. 5. Stewart, H. H.: Reconstruction of the urethra for the treatment of severe urethral strictures. Brit. J. Urol., 32: 1, 1960. 6. Leadbetter, G. W., Jr.: A simplified urethroplasty for strictures of the bulbous urethra. J. Urol., 83: 54, 1960. 7. Gil-Vernet, J. M.: Un traitment des stenoses traumatiques et inflammatoires de l'uretre posterieur. Nouvelle methode d'uretroplastie. J. Urol. Nephrol., 72: 97, 1966. 8. Blandy, J.P., Singh, M. and Tresidder, G. C.: Urethroplastyby scrotal flap for long urethral strictures. Brit. J. Urol., 40: 261, 1968.

9. Blandy, J.P., Singh, M., Notley, R. G. and Tresidder, G. C.: The results and complications of scrotal-flap urethroplasty for stricture. Brit. J. Urol., 43: 52, 1971. 10. Browne, D.: An operation for hypospadias. Proc. Roy. Soc. Med., 42: 466, 1949. 11. Swinney, J.: Urethroplasty in the treatment of strictures. Proc. Roy. Soc. Med., 47: 395, 1954. 12. Fernandes, M., Orandi, A. and Draper, J. W.: Urethroplasty: a new method of closure. J. Urol., 96: 779, 1966. 13. Cecil, A. B.: A radical operation for the cure of intractable stricture of the male urethra. J. Urol., 75: 501, 1956. 14. Whitehead, E. D. and Morales, P.A.: Complications ofurethroplasty for stricture. J. Urol., 107: 412, 1972. 15. Fernandes, M. and Draper, J.: Two stage urethroplasty. Improved method for treating bulbomembranous strictures. Urology, 6: 568, 1975. 16. Blandy, J.: Urethroplasty in males. In: Recent Advances in Urology. Edited by W. Hendry. New York: Churchill-Livingstone, No. 2, pp. 208-231, 1976. 17. Brendler, H. and Jacobson, L. E.: Evaluation of the scrotal inlay procedure (Turner-Warwick) for strictures of the deep urethra. J. Urol., 105: 256, 1971. 18. Ashken, M. H.: A personal experience with 37 Turner-Warwick scrotal inlay urethroplasties. Brit. J. Urol., 46: 313, 1974. 19. Reid, R.: Turner-Warwick urethroplasty and urethral stricture: results in 60 patients. Urology, 6: 711, 1975. 20. Colapinto, V. and McCallum, R. W.: Urinary continence after repair of membranous urethral stricture in prostatectomized patients. J. Urol., 115: 392, 1976. 21. Turner Warwick, R., Whiteside, C. G., Arnold, E. P., Bates, C. P., Worth, P.H. L., Milroy, E.G. J., Webster, J. R. and Weir, J.: A urodynamic view ofprostatic obstruction and the results ofprostatectomy. Brit. J. Urol., 45: 631, 1973. 22. Devine, C. J.: Comment on article by Brannan and associates. 23 J. Urol., 115: 680, 1976. 23. Brannan, W., Ochsner, M. G., Fuselier, H. A. and Goodlet, J. S.: Free full thickness skin graft urethroplasty for urethral stricture: experience with 66 patients. J. Urol., 115: 677, 1976. 24. Blandy, J. P. and Singh, M.: The technique and results of onestage island patch urethroplasty. Brit. J. Urol., 47: 83, 1975. 25. Thompson, I. M., Ross, G., Jr. and Ray, D.: Urethral flap urethroplasty. J. Urol., 103: 753, 1970.

Two-stage urethroplasty for urethral stricture disease.

Vol. 118, September THE JOURNAL OF UROLOGY Printed in U.SA. Copyright © 1977 by The Williams & Wilkins Co. TWO-STAGE URETHROPLASTY FOR URETHRAL ST...
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