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Two-Stage Urethroplasty: Surgical Technique and Complications

Indications for Single-Stage Urethroplasty

Two-stage urethroplasty is indicated for definitive treatment of complex and long-segment urethral strictures, especially after failure of a one-stage surgical procedure (Schreiter et al., 1998).

Contraindications

• Untreated urinary tract infections
• Coagulation disorders
• Low life expectancy or increased surgical risk due to comorbidity.

Surgical Technique of Two-Stage Urethroplasty

Preoperative Patient Preparations

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

First Stage:

Perineal or penile approach to the urethra. Incise the urethra longitudinally over the complete stricture length, followed by complete resection of the scared urethra and spongiofibrosis. Cover the tissue defect with subcutaneous tissue and above it with split skin or oral mucosa. Insert a transurethral catheter and change wound dressings daily for at least one week until the graft is fixed and heals well. After discharge, the patient micturates via the perineal urethral opening.

Second Stage:

The second stage is possible after complete healing of the graft, which takes several months. Perform a circumferential skin incision around the graft. Mobilize the lateral edges of the graft without compromising the vascular supply. Form a neo-urethra and close is with a running longitudinal PDS 4-0 suture over an 18 CH catheter. If possible, cover the neourethra with a Dartos flap or subcutaneous tissue from the penile shaft before skin closure. Insert a suprapubic catheter.

Postoperative Care:

Early mobilization, thrombosis prophylaxis, and regular physical examination of the incision wound. Transurethral catheter for one week, and leave the suprapubic catheter for another two weeks. After three weeks, examine graft healing and urethral sufficiency by antegrade urethrography. If healing is insufficient, leave the suprapubic catheter for an additional 1–2 weeks.

Complications

• The recurrence risk is around 80%, recurrent strictures may occur more than ten years after surgery.
• Other complications: erectile dysfunction, penile shortening, penile deviation, and urethrocutaneous fistula.

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.

Schreiter 1998 SCHREITER, F.: Die zweizeitige Urethraplastik.
In: Urologe A
37 (1998), S. 42–50

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 – zweizeitige Technik mit Gewebetransfer