Strictures
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
Buccal mucosal graft harvest
- 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
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
- 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 graft
- 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
Follow-up plan
- Discharge from PACU unless health concerns
- Keep foley x3 weeks
- Perform cystogram to assess for extravasation, give dose of antibiotics on day of removal