Reconstructive Urethral Surgery (eBook)

Preface 5
Contents 6
List of Contributors 7
1 Introduction 9
Fundamentals 12
2 Historical Highlights in the Development of Urethral Surgery 13
3 Anatomy and Blood Supply of the Urethra and Penis 19
3.1 Structure of the Penis 20
3.2 Deep Fascia (Buck’s) 20
3.3 Subcutaneous Tissue (Dartos Fascia) 21
3.4 Skin 21
3.5 Urethra 21
3.6 Superficial Arterial Supply 21
3.7 Superficial Venous Drainage 22
3.8 Planes of Cleavage 22
3.9 Deep Arterial System 23
3.10 Intermediate Venous System 24
3.11 Deep Venous System 25
References 25
4 Fundamentals and Principles of Tissue Transfer 27
4.1 Tissue Composition and Physical Characteristics 28
4.1.1 Tissue Composition 28
4.1.2 Vascularity 29
4.1.3 Tissue Characteristics 29
4.2 Tissue Transfer Techniques 30
4.2.1 Grafts 30
4.2.2 Flaps 32
4.3 Conclusion 35
References 35
5 Tissue Engineering – The Future of Urethral Reconstructive Surgery? 37
5.1 Introduction 38
5.2 Body Material 38
5.3 Synthetic Materials 38
5.3.1 Animal Studies 38
5.3.2 Synthetic Materials 38
5.3.3 Acellular Tissue 38
5.4 Clinical Trials 40
5.5 Conclusion 40
References 41
6 Hypospadia Repair: The Past and the Present – Also the Future? 43
6.1 Introduction 44
6.2 Incidence and Indication 44
6.3 Results 48
6.4 Hypospadia Cripples 48
6.5 Conclusion 48
References 49
7 Urethral Reconstruction in Women 51
7.1 Urethral Function 52
7.2 Etiology of Urethral dysfunction 52
7.2.1 Neural Causes 52
7.2.2 Loss of Both Continence and Conduit Function Related to Neural Dysfunction 52
7.3 The Relationship Between Upper Tract Function and Outlet Resistance 54
7.4 Diagnosis of Proximal Urethral Failure 54
7.5 Surgical Techniques for Creation of a Competent Proximal Urethral Sphincter 55
7.6 Urethral Injury, Tissue Loss, and Erosion 56
7.6.1 Etiology 56
7.6.2 Inability to Catheterize per Urethra 57
7.6.3 Surgical Repair 57
7.6.4 Urethral Closure 57
7.6.5 Failure of Urethral Closure 59
7.6.6 Posterior Urethral Erosion and Tissue Loss 59
7.7 Procedure 59
7.7.1 Intrinsic Sphincter Deficiency 59
7.7.2 Pseudodiverticula 62
7.7.3 Primary Urethral Obstruction 63
7.8 Urethral Problems After Stress Incontinence Surgery 64
References 66
8 A Current Overview of the Treatment of Urethral Strictures: Etiology, Epidemiology, Pathophysiology, Classification, and Principles of Repair 67
8.1 Urethral Strictures 68
8.1.1 Pathophysiology 68
8.1.2 Congenital Urethral Strictures 68
8.1.3 Acquired Urethral Strictures 68
8.2 Diagnosis and Evaluation of Urethral Strictures 70
8.3 Reconstructive Surgical Techniques 72
8.3.1 Visualization 72
8.3.2 Cautery 72
8.3.3 Instrumentation 72
8.3.4 Sutures 72
8.3.5 Surgical Positions 72
References 73
Therapy, Principles 75
9 The Acute Posterior Urethral Injury 77
9.1 Anatomy and Pathogenesis of the Urethral Injury 78
9.3 Diagnosis 80
9.4 Treatment 80
9.4.1 Surgical Technique: Early Realignment 81
9.4.2 Surgical Technique: Delayed Reconstruction 81
9.5 Results 82
9.6 Conclusion 83
References 83
10 The Endoscopic Treatment of Post-Traumatic Membranous Urethral Strictures 85
References 88
11 Endoscopic Realignment of Post-Traumatic Membranous Urethral Disruption 89
References 93
12 The Role of Bouginage, Visual Urethrotomy, and Stents Today 95
12.1 Visual Urethrotomy 96
12.2 Bouginage 97
12.3 Urethral Stents 98
References 99
13 Alternative Endourological Techniques in the Treatment of Urethral Strictures – Review of the Current Literature 101
13.1 Balloon Dilatation 102
13.1.1 Results 103
13.1.2 Critical Assessment 103
13.2 Urethral Stents 103
13.2.1 Results 104
13.2.2 Critical Assessment 104
13.3 Laser Urethrotomy 105
13.3.1 Results 105
13.3.2 Critical Assessment 105
13.4 Endoscopic Urethroplasty 105
13.4.1 Results 106
13.4.2 Critical Assessment 106
13.5 Endoscopic Treatment of a Complete Urethral Occlusion 106
13.5.1 Results 107
13.5.2 Critical Assessment 108
13.6 Conclusion 108
References 109
One-Stage Procedures 113
14 Reconstruction of the Bulbar and Membranous Urethra 115
14.1 Introduction 116
14.2 Acute Management of Posterior Urethral Trauma 116
14.3 Delayed Repair 117
14.3.1 Indications 117
14.3.2 Counterindications 117
14.3.3 Instruments and Suture Material 118
14.4 Surgical Technique 118
14.4.1 Reconstruction of the Bulbar Urethra 118
14.4.2 Reconstructing the Membranous Urethra (Bulboprostatic Anastomosis) 122
14.4.3 Surgical Approach 122
14.4.4 Partial Resection of the Symphysis 125
14.4.5 Finishing the Anastomosis 125
14.4.6 Results and Risks of the Surgery 125
14.5 Buccal Mucosa Onlay Plasty 126
14.6 Conclusion 128
References 128
15 The Sagittal Posterior (Transcoccygeal Transrectal Transsphincteric) Approach for Reconstruction of the Posterior Urethra 129
15.1 Introduction 130
15.2 Patient Preparation 130
15.3 Surgical Technique 130
15.4 Postoperative Care 135
15.5 Complications 135
15.6 Author’s Comments 135
References 136
16 The Use of Flaps in Urethral Reconstructive Surgery 137
16.1 Genital Vascular Supply 138
16.2 Principles of Flap Anatomy 139
16.2.1 Physical Characteristics of the Flap 139
16.2.2 Flap Vascularity 139
16.2.3 Mechanics of Elevation and Flap Transfer 139
16.3 Surgical Procedure 140
16.3.1 Preoperative Evaluation and Preparation 140
16.3.2 Surgical Technique 141
16.3.3 Postoperative Course 143
16.4 Conclusions 144
References 144
17 Reconstruction of the Fossa Navicularis 145
17.1 Reconstruction of Acquired Meatal Stenosis and Strictures of the Fossa Navicularis 146
17.2 Reconstruction of Childhood Meatal Stenosis 146
17.2.1 Isolated Stricture of the Fossa Navicularis Following Transurethral 147
17.2.3 Stricture Associated with Early Balanitis Xerotica Obliterans 150
17.3 Stricture of the Fossa Navicularis with Redundancy of Dorsal Penile Skin 150
17.4 Results 150
References 151
18 Penile Circular Fasciocutaneous Flaps for Complex Anterior Urethral Strictures 153
18.1 Penile Fascial Anatomy 154
18.2 Flap Anatomy 156
18.3 Patient Selection 156
18.4 Preoperative Preparation 156
18.5 Patient Positioning 156
18.6 Flap Harvest 157
18.7 Stricture Exposure 158
18.8 Anastomosis 159
18.9 Postoperative Care 160
References 160
19 Selective Use of the Perineal Artery Fasciocutaneous Flap (Singapore) in Urethral Reconstruction 161
Basics of the Fasciocutaneous Flap 162
History of Singapore Flaps 162
Flap Design and Elevation 163
Urethral Reconstruction 164
Technique of Onlay Patch Urethroplasty 164
Techniques of Tube Flaps Urethral Replacement 165
Perineal Artery 166
Clinical Experience 168
Conclusion 168
References 168
20 Anterior Urethral Stricture Repair and Reconstruction in Hypospadias Cripples 169
20.1 Introduction 170
20.2 Patient Preparation for Surgery 170
20.3 Instruments 170
20.4 Surgical Procedures According to the Type of Stricture – Step by Step 171
20.5 Tips and Tricks 181
20.6 Possible Complications 181
20.7 Remarks 181
References 181
21 The Use of Free Grafts for Urethroplasty 183
21.1 Introduction 184
21.2 Grafts Versus Flaps 184
21.3 The Principles of Grafting 184
21.4 Summary of Principles 185
21.5 Urethroplasty Using Free Grafts 185
21.6 Bulbar Urethroplasty 185
21.7 Penile Urethroplasty 185
21.8 Points of Technique 186
References 187
22 Repair of Bulbar Urethra Using the Barbagli Technique 189
22.1 Introduction and Historical Background 190
22.2 Anatomical Remarks 190
22.3 Step-by-Step Surgical Details 191
22.4 Long-Term Results and Attrition Rate of the Barbagli Procedures 195
22.5 Conclusions 195
References 195
23 Indications and Limitations of Buccal Mucosa Reconstructive Urethral Surgery in Hypospadias Repair 197
23.1 Introduction 198
23.2 Incidence and Etiology of Hypospadias 198
23.3 Indications and Operative Technique for Hypospadias Repair 198
23.4 Preoperative, Intraoperative, and Postoperative Management 199
23.5 Buccal Mucosa Urethroplasty 199
23.6 Results of Hypospadias Repair 201
References 202
24 Indications and Limits for the Use of Buccal Mucosa for Urethral Reconstruction 203
24.1 Introduction 204
24.2 Indications for the Use of Buccal Mucosa for Urethral Reconstruction 204
24.3 Preoperative Preparation 204
24.4 Operative Technique 204
24.5 Dressing Technique 205
24.6 Perioperative Treatment 206
24.7 Conclusions 210
Editorial Comment 210
References 210
Two-Stage Procedures 212
25 Two-Stage Mesh-graft Urethroplasty 213
25.1 Introduction 214
25.2 Basic Considerations in Complex Urethral Strictures 214
25.3 Pathophysiology 214
25.4 Preparing for Surgery 214
25.5 Surgical Technique 215
25.6 Tricks and Pitfalls in Mesh-Graft Urethroplasty 222
References 223
Subject Index 225

9 The Acute Posterior Urethral Injury (p. 69-71)

Posterior urethral disruption and distraction injuries present the most devastating and formidable challenges to the reconstructive urologic surgeon dealing with urinary tract trauma. Subprostatic pelvic fracture urethral distraction defects represent a traumatic disruption in continuity with minimal loss of urethra but with displacement of the two ends in the anteroposterior or cephalocaudal planes. Historical reports of surgical care of this injury are replete with management techniques resulting in lifelong sequelae of recurrent stricture, incontinence, and erectile dysfunction.

The development and refinement of anastomotic techniques to restore continuity to the urethra, magnetic resonance imaging to identify and define the injury, duplex ultrasound to avoid and understand the vascular injuries, and a revised classification have impacted and affected the successful outcomes now achieved in resolving this injury. The long-standing controversy surrounding initial management by early intervention with primary realignment vs delayed surgical repair after preliminary cystotomy diversion remains a contentious debatable issue, with reported success with alignment over a stenting catheter varying between 15% and 94% [1]. Advocates of either approach to surgical care of this injury have traditionally focused on the development of impotence and incontinence as a potential complication of the surgical technique. However, it is increasingly evident that the length of the distraction defect and subsequent development of incontinence and impotence are related more to the severity of the injury and the extent of the anatomical disruption, both bony and soft tissue, rather than the surgical approach itself [2, 3].

9.1 Anatomy and Pathogenesis of the Urethral Injury

Pelvic fractures are the major source and etiology of posterior urethral distraction injuries, occurring at a rate of 20 per 100,000 population. Motor vehicle and motorcycle injuries are associated with the highest incidence of pelvic fractures (15.5%) followed by pedestrian injuries (13.8%), falls from heights greater than 15 ft (13%), car occupants (10.2%), and occupational crush trauma (6%). The majority of injuries occur in the first four decades, with a mean age of 33 years including an 8% pediatric occurrence (<,12 years). Pelvic fractures are a marker of severe post-traumatic injury and are associated with intra-abdominal and urogenital injuries in 15%–20% of patients. The most commonly injured organ in pelvic fractures is the posterior urethra (5.8%–14.6%), followed closely by the liver (6.1%–10.2%) and the spleen (5.2%–5.8%) [4].

The bladder and bladder neck are frequently involved, and injury to these structures needs to be identified and included in the equation of the surgical strategy. Associated perforation injury of the rectum is critical to identify but rarely seen with pelvic fracture trauma [17]. The life-threatening injuries take precedence in diagnosis and management over the urethral injury, but in those patients who survive, the urethral injury will be the source of chronic complex disability and morbidity. Urinary incontinence in the male depends on the bladder neck proximally and the external sphincter distally. The distal external sphincter mechanism may be destroyed by this posterior urethral injury or during subsequent reconstruction and continence will, therefore, be dependent on bladder neck function alone. Most men, however, are continent following repair of this injury and will reveal a closed bladder neck on preoperative cystography and cystoscopy. A few patients will be noted to have a persistently open, funneled bladder neck or a bladder neck quadrant scar seen on transvesical cystoscopy, which support the potential of a concomitant bladder neck injury.