Potential complications
- Stricture recurrence: 10-20% depending on technique, more likely with longer stricture, prior surgery, tubularized graft
- Penile shortening/chordee: occurs with insufficient mobilization or graft not used
- Cold glans: less likely with non-transecting urethroplasty
- Erectile dysfunction: reported in 2%, less likely with non-transecting
- Ejaculatory dysfunction: from injury to bulbospongiosus muscle
- Diverticulum: less likely with graft (vs flap) and dorsal onlay
- Voiding dysfunction: increased risk in older patients likely due to underlying detrusor dysfunction
Follow-up plan
- Discharge from PACU unless health concerns
- Keep foley x3 weeks
- Perform voiding cystourethrogram (VCUG) to assess for extravasation, give dose of antibiotics on day of removal
- Perform symptom check at 6 weeks, 6 months, 1 year, then as needed
Buccal mucosal graft harvest
- Confirm whether patients chews on a preferred side, check to make sure no oral lesions
- Give cefoxitin and gentamicin for antibiotic prophylaxis
- Place u-drape with opening towards genitals
- Place mouth retractor and lip retractor, secure together with Penrose and allis clamp
- Place lip stitch X3 3-0 silk pops, place stitch within mouth and come out right at vermillion border
- Delineate stensen duct (do not include within graft) and measure out graft, usually adding 1cm length and using ~2-3cm width
- Use lidocaine 1% w epi to hydrodissect under graft, starting proximal and moving distal
- Cut with #15 scalpel, push deep to maintain smooth incision
- Place silk traction stitch at distal tip of graft, either x2 or figure of 8 for traction
- Use curved metzenbaum scissors to dissect off underlying layers, trying to leave as much muscle behind as possible
- Obtain minimal hemostasis (avoid cautery injury), then place tonsil balls X3 (tie tails together) soaked in residual lido/epi for compression
Perineal Repairs
Urethral access
- Place patient in dorsal lithotomy, prep/drape, give antibiotics (cefazolin/cefoxitin +/- gentamicin)
- Perform cystoscopy, place double floppy wire if stricture not obliterated
- Make midline perineal incision with scalpel, divide underlying layers
- Place lone star retractor, place hooks to retract skin, larger rakes for scrotal retraction
- Divide bulbospongiosus with metzenbaum scissors (do not use cautery), identify urethra
Excision and Primary Anastomosis
- Circumferentially free urethra proximally and distally to allow for adequate mobilization
- Place cystoscope to identify stricture and mark site with cautery on outside of urethra
- Place 3 clamps - two at distal stricture site, then 3rd clamp very proximal to control sponge bleeding
- Cut urethra with heavy scissors
- Continue to remove strictured urethra until it accommodates 22-26Fr bougie, send urethra for pathology
- Spatulate urethra - distal dorsally, proximal perineally
- Start placing 4-0 vicryl anastomotic stitches, starting at 12 on proximal urethra and moving counterclockwise, with tails out outside
- Tip: place catheter after 6 o'clock stitch, ensuring it does not tangle the already-placed sutures and that the new sutures don't tag the catheter
- Tip: place dorsal stitches full thickness (9 to 3), place ventral stitches only through mucosa and not the spongiosum (8 to 4)
- After all stitches placed, tie down starting with 12 o'clock and moving counterclockwise, tying in order, confirm catheter is still mobile
- Close ventral spongiosum with 5-0 PDS running stitch
Dorsal onlay buccal mucosa graft (preferred for penile stricture)
- Choose one side of urethra and divide urethra from surrounding tissue until dorsal portion is accessible
- Place 22Fr Bougie through meatus to level of distal stricture, mark urethra and start dorsal incision 1cm distal
- Incise further proximal until able to pass 22-28Fr Bougie, then perform cystoscopy to confirm no bladder abnormalities, can retract urethra with 4-0 vicryl retracting stitches through urethral edge
- Take fenestrated graft and suture (with 4-0 vicryl) at 5, 6, and 7 o'clock at proximal portion of graft, suture graft directly to urethra, then suture distal apex to hold in place
- Place 4-0 vicryl interrupted sutures on both edges - on side with native urethra, suture urethral edge + corpus underneath + graft edge
- Place 6-0 monocryl on TF needle in running fashion to quilt graft and hold it onto corpus, be careful not to wrinkle or tug on graft
- Place running 5-0 PDS on urethral edge, include corpus underneath
- Place catheter and run 5-0 PDS x2 from top and bottom to close urethra completely
Ventral onlay buccal mucosa graft (preferred for long bulbar strictures)
- Place 24Fr bougie and incise directly over widest part with #15 scalpel to avoid underestimating stricture, use fingers to push urethra onto bougie, place traction stitch with 4-0 vicryl pop (but do not tie) to provide hemostasis (ensure mucosa included in stitch), place mosquito snap and hang traction stitches on lone star
- Continue cutting proximally sharply with Metzenbaum scissors until stricture accommodates 24Fr bougie, make sure to see/feel the wire within the urethral lumen to make sure false passages aren't created
- Place graft with mucosal side inwards, anchor proximally with 4-0 vicryl at 5, 6, and 7 o'clock (place all stitches into urethra first, then graft, then tie)
- Tip: place stitches into mucosa and portion of spongiosus, but leave tunica for separate closure
- Run 5-0 PDS 80% up one side and 20% up the other side, cutting out traction stitches as they become less helpful for retraction, then place 16Fr catheter
- Continue running PDS until 80% on both sides
- Repeat 4-0 vicryl x3 stitches on distal portion of grat
- Close remaining opening with running 5-0 PDS or interrupted 4-0 vicryl to avoid redundant graft (trim as needed)
- Close spongiosus over graft with 4-0 PDS
Closure
- Close bulbospongiosus and colles with 2-0 vicryl running
- Close skin with 4-0 monocryl horizontal mattress interrupted
- Place bacitracin, telfa, and compressive dressing
Distal penile repair
- Position supine, prep/drape genitals and mouth
- Place midline glans traction stitch and traction stitches through meatus at 5 and 7 o'clock
- Place wire if able into urethra
- Use #15 blade to incise scar tissue ventrally until scar springs open, make sure to incise proximal enough (use nasal speculum for exposure)
- Perform cystoscopy to confirm no abnormalities in urethra or bladder
- Measure out defect and harvest triangular buccal or lingual graft, place traction stitch at both distal corners
- Create double-armed ski needle with PDS
- Place double-armed stitch through proximal apex of graft, then use needles to place through apex of stricture, stitches will exit the ventral penile skin, pulling stitches tight with "parachute" the graft into the urethra, tie stitches and cut
- Trim excess graft then place double-armed stitches through each side of the graft and tie in place to secure the lateral edges of the graft
- Place interrupted stitches to hold graft to meatus
- Place 1 or more double-armed stitches as quilting stitches in the middle of the graft
- Place catheter, bacitracin, telfa, and kerlex dressing
1-stage flap/graft foreskin repair
- Position supine, prep/drape genitals
- Can perform cystoscopy via suprapubic tract if present, place wire across stricture if able
- Place silk traction glans stitch at midline
- Make circumcising incision 7mm proximal to corona
- Using littler scissors, deglove the shaft (assist exposes tissue by grasping with adsons), separating superficial and deep Buck layers, if done correctly should be able to visualize dorsal vasculature without entering vessels
- If distal exposure needed, can separate glans wings off underlying tissue by dissecting along same plane
- Place 24Fr bougie into meatus, then incise urethra over bougie with #15 blade, place full-thickness 4-0 vicryl traction stitches
- Cut ventral urethra until normal urethra is reached, place traction stitches along the way to prevent mucosal retraction, can also place stitches at apices
- Perform cystoscopy to confirm no other urethral or bladder abnormalities (can also be done via suprapubic tract)
- May need to cut out dorsal scar tissue to expose healthy underlying tissue for graft placement
- For flap, delineate desired boundaries with marking pen, incise gently with #15 scalpel, then dissect off proximal tissue, taking care not to devascularize the flap by going to shallow or deep
- For graft, delineate desired boundaries with marking pen, incise gently with #15 scalpel, then dissect off underlying layers to obtain only epithelium, then fenestrate graft with #11 blade (secure to needle board with small gauge needles), then place apical traction stitches to assist with placement
- Place graft in dorsal urethra, secure into place with interrupted 4-0 vicryl, make sure graft reaches healthy urethra, trim any excess graft
- Quilt graft with 4-0 monocryl on taper needle x2
- Secure flap at proximal and distal apices with 4-0 vicryl stitches
- Run nearer flap side with 4-0 PDS suture, then run part-way up the other side before placing 16Fr catheter, then complete the other side, pull back catheter to ensure not trapped by stitch
- Complete circumcision ensuring tissue appears even, can tack down excess dartos for evenness and flap protection
- Complete circumcision incision with running or interrupted monocryl stitches
- Apply bacitracin, telfa, and coban dressing