Many of our patients are referred to our institution with recurrent strictures after failed surgery. When the previous surgery was excision and primary repair of a short bulbar or membranous stricture, and the recurrence is short, primary repair can again be performed. One example is a 10-year-old boy who was hit by a car and suffered a pelvic fracture and an associated urethral injury. His local pediatric urologist performed a repair complicated by early failure, and then another repair also complicated by an early failure. He was then referred to our Institution and the RUG obtained revealed a total obliteration.
The most likely cause of the failures was a lack of proximal exposure and incomplete scar excision. This is not uncommon when this surgery is performed by an inexperienced surgeon and represents a technical complication. We performed a complex re-do repair with complete scar excision and he had an excellent technical outcome and subsequently was able to urinate normally. Others exclusively specialized in male reconstructive surgery have reported excellent results with re-do excisional repair.
In other cases, the recurrent stricture length precludes excisional repair. Tissue transfer reconstruction is then required. In general, we have found that buccal mucosa is current the best graft material, but the supply is limited. Other tissue options include split-thickness skin grafts from the thigh and penile skin (when available).
Particularly challenging problems are long total urethral obliterations. When there is a total obliteration of the penile urethra, and penile skin is available, we prefer to use a combination of penile skin (flap) and buccal mucosa graft to reconstruct the urethra. As shown, the penile skin is “de-gloved”, exposing the obliterated urethra. We then open the normal urethra at the base of the penis.
Buccal mucosa is then added along the undersurface of the penis to create a strip of new urethra, and the penile skin is then used as an onlay to complete the repair as the new urethra is tubularlized. Our experience with this technique was recently accepted for publication in the Journal of Urology (September, 2011)
In 1999, a patient presented to our institution after urethral stent placement and subsequent removal complicated by a 5 cm total obliteration of the bulbar urethra.
RUG of 5 cm Obliteration
Penile skin was not available and in general, it has been reported that when tissues are rolled into tubes to reconstruct the entire circumference of the urethra, the outcomes are poor. One option would have been a two-stage repair. However, this patient was instead reconstructed in one surgery using a new technique modified by Dr. Gelman.
An incision was made under the scrotum (perineal incision), esposing the obliterated urethra. We then rotated and incised the structure that surrounds the urethra (corpus spongiosum) and extended the incision into the healthy normal urethra at both ends of the obliterative stricture as shown.
Buccal mucosa was quilted to to the corpus spongiosum to reconstruct a portion of the urethra (ventral portion) as shown below. Then, a second graft was quilted to the undersurface of the penis as previously described by Barbagli as this technique is successful when used to patch and enlarge a narrow urethra. These two grafts were then connected to form a tube.
A retrograde urethrogram performed three years after surgery revealed no deterioration and a widely patent urethra. With 11-year follow-up, this patient has not had a recurrent stricture and remains asymptomatic.
RUG After Repair
Dr. Gelman subsequently used this new technique on many occasions with excellent results. The approach to recurrent long strictures is individualized based on many factors including the exact location and length of the stricture, the presence or absence of multiple strictures, the availability of penile skin, the integrity of the tissues surrounding the urethra, and other factors.