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Single Stage Urethroplasty With Oral Mucosa Grafts

Indications for Single-Stage Urethroplasty

Urethroplasty with oral mucosa grafts is the method of choice for definitive treatment of significant urethral strictures after failure of endoscopic therapy (Jordan et al., 1998) (Morey et al., 1998).

Contraindications

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

Surgical Technique of Single-Stage Urethroplasty

Preoperative Patient Preparations

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

Surgical approach:

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

Urethrotomy:

Open the urethral stricture with a longitudinal urethrotomy. Use a thick urethral bougie for orientation, marking the stricture's distal end. The lumen is enlarged by tissue transfer; the grafting can be placed dorsally, laterally, or ventrally (depending on the location of the urethrotomy). For free tissue transfer, oral mucosa is used, and urinary bladder mucosa or skin grafts are used less frequently.

Onlay Repair:

Stay sutures through all layers of the urethra and corpus spongiosum facilitate anastomosis and reduce bleeding. Place corner sutures PDS 5-0 between the graft and distal and proximal ends of the urethrotomy, grasping only the urethral mucosa. Continue with a running suture between the corner sutures, and insert an 18–20 CH catheter before completion. Close the corpus spongiosum with a running suture (PDS 5-0) after ventral grafting.

Tubularized Flap:

In rare cases, a tubularized tissue transfer is necessary after complete resection of the urethral stricture. Tubular flaps tend to have a higher complication rate. For pedicled tissue transfer, prepuce or penile shaft skin is used, similar to hypospadias surgeries. For long-segment reconstruction, a combination of tissue transfer techniques is possible, e.g., pedicled skin flaps combined with free oral mucosa graft.

Wound Closure:

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, and regular physical examination of the incision wound. Transurethral catheter for three weeks. Examine graft healing by antegrade/retrograde urethrography and, if necessary, also with cystoscopy. If graft healing is insufficient, insert a transurethral catheter for an additional 1–2 weeks.

Complications

• Recurrence risk: 10–30%. Risk factors for recurrence are stricture length, tubular reconstructions, and grafting with penile or scrotal skin.
• Other complications: erectile dysfunction, penile shortening, penile deviation, urethrocutaneous fistula, and urethral diverticulum.

References

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

Jordan 1998 JORDAN, G. H.: Grundlagen und Prinzipien des Gewebetransfers.
In: Urologe A
37 (1998), S. 180–194

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

Morey und McAninch 1998 MOREY, A. F. ; MCANINCH, J. W.: Therapie der Harnröhrenstriktur unter Verwendung freier Transplantate.
In: Urologe A
37 (1998), S. 38–42

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 – einzeitige Technik mit Gewebetransfer