You are here: Urology Textbook > Surgery (procedures) > Anastomotic urethroplasty

Anastomotic Urethroplasty: Surgical Technique and Complications

Indications for Anastomotic Urethroplasty

Urethroplasty with primary anastomosis is the method of choice for definitive treatment of short urethral strictures after failure of endoscopic therapy (Olianas et al., 1998).

Contraindications

• Untreated urinary tract infection
• Coagulation disorders
• Stricture too long for tension-free anastomosis
• Low life expectancy, increased surgical risk due to comorbidity.

Surgical Technique of Anastomotic Urethroplasty

Preoperative Patient Preparations

• Perioperative antibiotic prophylaxis: e.g., 2nd generation cephalosporin.
• Anesthesia: general or spinal anesthesia.
• Patient positioning: lithotomy position.

Surgical approach:

Perineal or penile midline incision for the approach to the urethra.

Excision of the Scar Tissue:

Excise the stricture after identification and mobilization of the urethra. Both urethral ends must be free of scarring and anastomosis should be possible without significant tension. The closer the stricture is to the membranous urethra, the longer the stricture length can be for a successful anastomosis.

Anastomosis:

Spatulate the proximal and distal urethra at 180 degrees apart. Insert an 18–20 CH transurethral catheter. Suture the urethral anastomosis with interrupted stitches analogous to fig. ureteroureterostomy with PDS 4-0.

Non-Transecting Anastomotic Bulbar Urethroplasty (NTABU):

NTABU is a treatment option with fewer complications for short bulbar urethral strictures without pronounced spongiofibrosis. The first steps are identifying and mobilizing the bulbar urethra and incision of the stricture in a longitudinal direction until healthy tissue is seen on both sides. The annular scar is excised. The ventral mucosal defect is adapted transversely with interrupted sutures. The dorsal incision of the bulbar urethra is also closed transversely. If necessary, augmentation with oral mucosa can facilitate urethral closure (Bugeja et al., 2015).

Wound Closure:

Close the corpus spongiosum at the bulbar urethra with additional sutures. A drain is usually unnecessary. Readapt the bulbospongiosus muscle with a running suture Vicryl 2-0. Close the subcutaneous tissue with interrupted sutures.

Postoperative Care:

Early mobilization, thrombosis prophylaxis, regular physical examination of the incision wound. Transurethral catheter for 10--14 days.

Complications

• Recurrence risk: 5–20%, depending on the indications. Short strictures, first open treatment trials, or bulbar localization are predictors for better results.
• Other complications: erectile dysfunction, penile shortening, penile deviation, penile shortening, and urethrocutaneous fistula. Avoiding complete urethral transection and preserving the bulbar vasculature reduces the risk of penile shortening, penile deviation, and erectile dysfunction.

References

S. Bugeja, D. E. Andrich, and A. R. Mundy, “Non-transecting bulbar urethroplasty.,” Translational andrology and urology, vol. 4, no. 1, pp. 41–50, 2015.

Gozzi, C.; Tritschler, S.; Bastian, P. J. & Stief, C. G. [Management of urethral strictures].
Urologe A, 2008, 47, 1615-1622

N. Lumen, F. C. Juanatey, K. Dimitropoulos, and F. E. Martins, “EAU Guidelines: Urethral Strictures,” 2023. [Online]. Available: https://uroweb.org/guidelines/urethral-strictures.

Olianas u.a. 1998 OLIANAS, R. ; OBERBECK, D. ; POTTEK, T. ; SCHREITER, F.: Bulbobulbäre und bulboprostatische Anastomose der Harnröhre.
In: Urologe A
37 (1998), S. 25–30

F. Schreiter and G. H. Jordan, Eds., Reconstructive Urethral Surgery. Springer Medizin Verlag Heidelberg, 2006.

H. Wessells, A. Morey, A. Vanni, L. Rahimi, and L. Souter, “AUA Guideline: Urethral Stricture Disease.” [Online]. Available: https://www.auanet.org/guidelines-and-quality/guidelines/urethral-stricture-guideline

  Deutsche Version: Offene Harnröhrenplastik – Technik und Komplikationen der End-zu-End-Anastomose