Stricture

Urethral Stricture Repair

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

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

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

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

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

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

Discharge from PACU unless health concerns
Keep foley x3 weeks
Perform cystogram to assess for extravasation, give dose of antibiotics on day of removal