Failed Anterior Urethroplasty: Guidelines for Reconstruction

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Failed Anterior Urethroplasty: Guidelines for Reconstruction
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  0022-5347/97/1584- 383 03.00/0 THE OURNAI. F UROLOGY Copyright 1997 y AMERICAN KO~ICAL SSOCIATION NC. Vol. 158. 1383-1387, October 1997 rinted in USA FAILED ANTERIOR URETHROPLASTY: GUIDELINES FOR RECONSTRUCTION ALLEN F. MOREY C. PACE DUCKETT AND JACK W. McANINCH* From the Departments of Urology Uniuersity of California School of Medicine and San Francisco General Hospital San Fmncisco California ABSTRACT Purpose: We analyzed the methods and outcomes of repeat urethroplasty in men with recurrent stricture after the failure of previous anterior urethroplasty. Materials and Methods: In 31 men with recurrent stricture after previous urethroplasty anterior urethral reconstruction was performed. Reconstructive methods varied according to stricture length and location. Results: End-to-end urethroplasty performed in 11 of 13 men with short (average 1.8 cm.) bulbar strictures was successful in all. Patch graft urethroplasty was successfully done in 4 men with intermediate (average 4.4 cm.) strictures. Penile circular fasciocutaneous flap urethroplasty performed in 13 of 14 men with long or distal strictures (average 8 cm.) was successful in 10 (79%). Overall excellent results were obtained in 28 of the 31 cases (90%). Conclusions: Guidelines for urethral reconstruction after failed anterior urethroplasty are predicated on stricture length, location and seventy. Circular fasciocutaneous flap urethroplasty is extremely versatile and effective for refractory long or distal strictures. End-to-end urethro- plasty with stricture excision is highly reliable for less extensive bulbar strictures for which previous operative repair has failed. Grafts are best used selectively in the reoperative setting. KEX WORDS: rethra. urethral stricture, reoperation, tissue transplantation Formal urethral reconstruction provides a higher chance for cure of the obliterative sequelae of stricture disease than endoscopic urethrotomy.1.2 We agree with Jordan and Schlossberg that cure rates of 95% can be achieved with 1-stage reconstruction in most initial repairs.3 However, strictures that recur after open urethroplasty appear to be associated with an increased risk of failure of subsequent reconstruction. Roehrborn and McConnell reviewed the out- comes of 110 urethroplasties and found that previous surgi- cal repair was more often associated with a negative outcome than any other clinical variable, and reoperative urethro- plasty yielded unsatisfactory results in 42%.4 Jakse and Marberger similarly reported a 93% overall success rate in 105 patients treated with stricture excision and oblique pri- mary anastomosis, although 5 of the 7 (71%) in whom this procedure failed had undergone prior urethr~plasty.~ e re- viewed the methods and outcomes of repeat urethroplasty in men with recurrent stricture after the failure of previous anterior urethroplasty in an attempt to develop guidelines for the approach to reconstruction in these high risk patients. PATIENTS AND METHODS From our data base of more than 400 urethroplasty pa- tients we reviewed our experience with 31 men who under- went urethral reconstruction for recurrent stricture after Previous open urethroplasty. The majority of patients were referred from elsewhere and in most, various endoscopic manipulations had also failed. In all patients strictures were located distal to the membranous urethra and all underwent Accepted for publication April 18, 1997. Read at annual meeting ofknerican Urological Association, New Orleans, Louisiana, April 12-17, 997. Requests for reprints: Department of Urology, U-575, niversity of California, San Francisco, California 94143-0738. Editor Note: This article is the third of 6 published in this i-ue for which category 1 CME c-ts cap be earned: In- hctions for obtaining credits are gven mth the questions On pages 1658 and 1569. 1-stage reconstruction. Surgical methods were individualized according to stricture location, severity and length. The lat- ter measurement was obtained by intraoperative meas- urement, sonourethography andfor conventional retrograde urethrography RESULTS Average followup was more than 1 year. Three patients underwent reoperative urethroplasty less than 1 year ago. Overall excellent results were obtained in 28 of the 31 pa- tients (go%), who void normally and have not required ure- thral dilation or instrumentation of any kind. Failure was documented by radiographic retrograde urethrography when recurrence of obstructive voiding symptoms prompted inter- vention. Patients were divided into 3 groups based on stric- ture length and location. Group 1-short bulbar strictures. Ln the 13 group 1 pa- tients strictures less than 3 cm. (average 1.8) were located in the bulbar urethra. Prior procedures included 6 end-to-end urethroplasties, 1 scrotal inlay, 1, 2-stage Johanson proce- dure and 3 circular fasciocutaneous flap reconstructions of long strictures with subsequent focal recurrence. The previ- ous method of urethroplasty was unknown in the remaining 2 cases. We performed end-to-end urethroplasty and stric- ture excision in 11 patients with excellent results. A 2-layer (urethra and spongiosum) wide caliber spatulated anastomo- sis was created, except in patients who had undergone a circular fasciocutyeous flap procedure, in whom a 1-layer (urethra only) anastomosis was constructed. In 1 of these patients a prestenotic redundant portion of the old flap was incised and rotated distally in an onlay fashion without stric- ture excision. In another patient a 2 cm. patulous, hair bear ing scrotal flap was excised next to a recurrent 1.5 cm. stric- ture, and a 4 cm. dorsal penile fasciocutaneous flap was sutured onto the common urethral plate (fig. 1 . Group 2 intermediate length bulbar strictures In the 4 group 2 patients bulbar strictures of intermediate length 1383  1384 RECONSTRUCTION OF FAILED ANTERIOR URETHROPLASTY FIG. 1. A preoperative retrograde urethrography shows short redundant scrotal flap beside short bulbar stricture. B postoperative x-ray aRer excision of hair bearing urethral tissue and dorsal preputial onlay flap. (average 4.4 cm.) were successfully repaired using 2-layer patch graft onlay technique. Previous procedures included end-to-end urethroplasty in 1 patient and 2-stage urethro- plasty in 2. In the remaining patient a 3 cm. stricture re- curred after UroLume stent* removal combined with 13 cm. circular fasciocutaneous flap reconstruction. We used buccal mucosal grafts in 3 cases and penile skin in 1. Group 3-1ong andlor distal strictures. In group 3, 14 patients had long or distal urethral strictures. The table shows the histories, and stricture length and location in this group. Excellent results were achieved in 11 cases (79 ). All 3 failures occurred in men with extensive strictures of the pendulous urethra, including 2 who had undergone tubular- ized flap procedures at our institution. Two men eventually required perineal urethrostomy and 1 who had a tubularized flap did well after a single optical urethrotomy. Penile circular fasciocutaneous flap urethroplasty was per- formed in 13 cases. In the remaining case 3 buccal mucosa grafts were used in continuity because severe balanitis xe- rotica obliterans had rendered the penile skin inadequate for flap development. Hair bearing flaps and redundant areas from previous procedures were excised at repeat urethro- plasty (fig. 2). In 1 patient in whom a large hair bearing scrotal flap was excised at the time of circular fasciocutane- ous flap urethroplasty persistent focal extravasation devel- oped, which resolved with prolonged catheter drainage alone. DISCUSSION The ideal therapy for recurrent stricture after open ure- throplasty has not been established. Repeat urethroplasty is frequently a complex and lengthy undertaking, which should only be attempted after carefully considering patient age, history, general health and therapeutic goals. When it is elected, we believe that the reconstructive method should be individualized according to length, location and severity of the fibrosis. Precise preoperative delineation of the magni- tude of urethral pathology is mandatory, and we have found sonourethrography to be a valuable adjunct to standard ra- diographic and endoscopic diagnostic maneuvers.6.7 In 1 series of reoperative urethroplasty Barbagli et a1 re- ported excellent outcomes in 12 of 20 cases (60%) n which the patch graft was the predominant procedure.8 Likewise, using primarily a patch graft technique Roehrborn and McConnell noted excellent results in 58% of reoperative cases.* Our experience with onlay grafts in urethroplasty has been ex- tremely gratifying but we use them selectively, preferring to apply them in bulbar rather than pendulous reconstruction.9 In the bulbar urethra closure of the highly vascular sur- rounding spongiosum over the graft with a separate layer of fine absorbable suture ensures graft stability and viability. When spongiosum closure is difficult due to fibrosis or failed previous urethral substitution procedures, we prefer to use a flap onlay technique. Grafts appear to have a limited role in the reoperative setting and they are best applied after failed end-to-end procedures. We currently use grafts as a last resort for distal strictures only when suitable genital skin is unavailable. In addition, we now use buccal mucosa grafts exclusively because they are highly reliable, well tolerated and may be harvested simultaneously in a 2-team approach, which shortens the duration of the procedure.1° We prefer vascularized tissue over free grafts for recon- structing most cases of recurrent stenosis, especially those occurring distally, in the pendulous area where the vascular- ity of the corpus spongiosum is relatively scant. The circular penile fasciocutaneous flap described by McAninch was the predominant technique selected in this series and onlay re- pairs were performed when possible. The distal penile skin in this technique is hairless, abundant and readily adaptable for strictures of any length, location and severity even in previously circumcised patients. Our 79 success rate with the circular fasciocutaneous flap technique supports the con- cept that vascularized flaps are generally more reliable than free grafts for repeat urethroplasty. This success is especially noteworthy because this technique was used in only the most complex cases. Other types of genital skin based flaps may be applied successfully. Jordan and Schlossberg reported excellent re- sults with an epilated midline longitudinal genital skin is- land flap for salvage urethroplasty in 6 patients. Regardless of the type of flap, it is important to specify in the operative dictation the direction of flap rotation when mobilizing gen- ital skin pedicles. Should reoperation be necessary, dissec- tion may then be done to favor the contralateral side and presellre the viability of previously mobilized tissues. We advocate wide excision of hair bearing or redundant areas of neourethra identified at reoperation with preservation of the urethral plate when possible. End-to-end urethroplasty with complete stricture excision and wide caliber, spatulated, tension-free anastomosis is the optimal method of urethral reconstruction. Schlossberg et al achieved excellent results in 52 of 54 consecutive patients (96 ) with strictures less than 3 cm.12 Likewise, Webster et a1 reported a 96% success rate for strictures of 1 cm. or less.13 We noted that repeat end-to-end urethroplasty was highly effective after previous failure (fig. 3). The 100% success rate in this series confirms the superiority of this technique and the validity of restricting its application to relatively discrete strictures. Our experience with cases in which previous end-to-end urethroplasty failed suggests that most failures were due American Medical Svstems. Minnetonka. Minnesota primarily to inadequate- excision of fibrosis andor inade-  RECONSTRUCTION OF FAILED ANTERIOR URETHROPLASTY Methods and outcomes of reoperative urethroplasty for long or distal strictures 1385 Procedure Outcome tricture Length cm.) Previous Reoperative Pt. No. 1 1.5 Penile skin ann grafts Penile circular fasciocutaneous flap Excellent 2 21 2-Stage urethroplasty Penile circular fasciocutaneous Excellent 3 3.0 Penile skin graft Tubularized penile circular fascio- Perineal urethrostomy 4 17.0 End-to-end 3 Buccal mucosal grah Excellent 5 8.0 Penile foreskin graft Penile circular fasciocutaneous flap Excellent 6 4.0 2-Stage Johanson Penile circular fasciocutaneous flap Excellent 7 8.0 Bladder mucosal graft Tubularized penile circular fascio- Required 1 direct vision cutaneous flap internal urethrotomy 7.0 End-to-end Penile circular fasciocutaneous flap Excellent 9 6.0 Penile skin graR End-to-end, penile circular fascio- Excellent flap, penile skin graft cutaneous flap cutaneous flap 2 strictures) 10 8.0 Penile shaft arm graft Penile circular fasfiocutaneous flap Perineal urethrostomy 11 15.0 Graft Penile circular fasciocutaneous flap Excellent 12 11.0 2-Stage Johanson Penile circular fasciocutaneous flap Excellent 13 11.0 2-Stage urethroplasty Penile circular fasciocutaneous flap Excellent 14 6.0 Orandi flap Penile circular fasciocutaneous flap Excellent FIG. 2. A retrograde urethrography shows long, grossly redundant scrota1 flap from failed previous urethroplasty. B hair bearing neourethra discovered at reoperation in another patient. Because circular penile fasciocutaneous flap provides 12 cm. or more for recon- struction, even large redundant or hair bearing areas of neourethra may be excised. Preservation of urethral plate allows subsequent flap onlay reconstruction. quate distal bulbar mobilization, resulting in excessive anas- tomotic tension. A contributing factor may be that radio- graphic retrograde urethrography frequently underestimates stricture length. We have observed that urethral ultrasound is more accurate and sonographic information frequently al- ters the reconstructive method selected, since approximately a third of strictures initially appearing amenable to end-to- end urethroplasty were found to be too long on ultra~ound.'~ We believe that the precision of sonourethrography has been instrumental in guiding patient selection and facilitating excellent results from end-to-end urethroplasty in our hands. Schreiter and No11 have advocated meshed split-thickness skin graft for use in 2-stage reconstruction of recurrent stric- tures. In their experience with 96 patients the success rate was 98% but stricture lengths were not d~cumented.'~ arr et a1 reported a success rate of 80% with meshed graft ure- throplasty in 15 patients, including 11 in whom urethro- Plasty had previously failed.16 Although meshed grafts ap- Pear to be reliable in complex reoperative cases, we believe that 1-stage reconstruction is preferable for and possible in nearly all cases. Recently an endourethral stent has been proposed for the treatment of refractory strictures.17.18 Although initial data appeared encouraging for some bulbar strictures, Milroy and Allen reported a 50% failure rate in cases of previous ure- throplasty and suggested that it be avoided in that clinical setting.'* We and others have found stricture regrowth through the interstices of the stent to be a source of recurrent obstruction. Also, removal of these stents often causes exten- sive urethral damage that necessitates total urethral re- placement at reconstruction. The surgical approach to repeat urethroplasty must be tailored to individual stricture length and location (fig. 4). Short recurrent bulbar strictures are usually amenable to end-to-end urethroplasty regardless of the previous method of reconstruction. Bulbar strictures of 2.5 to 6 cm. are too long and may be repaired with a single buccal mucosal graft. Buccal mucosal graft urethroplasty has the advantage of avoiding the extensive genital dissection required to develop and transfer vascularized flaps to the perineum. However, the spongiosum must be well vascularized and supple enough to close primarily over the graft. For longer strictures for which more than 1 graft would be required and for severe or distal strictures when spongiosum closure is problematic  1386 RECONSTRUCTION OF FAILED ANTERIOR URETHROPLASTY FIG. 3. A retrograde urethrography demonstrates short bulbar stricture. B persistent stricture after end-to-end urethroplasty performed elsewhere. C preoperative sonourethrography at reoperation reveals 9 mm. stricture. D after repeat end-to-end urethroplasty area of reconstruction is widely patent. PENDULOUS Fasciocutaneous 125rnm 26-60mm >60mm I J ptG2 q [CFFI or CFF EE = End-to-End FF = Penile Circular Fasciocutaneous Flap FIG. 4. Guidelines for reconstruction of recurrent urethral stric- ture after previous urethroplasty. 1-stage circular fasciocutaneous flap urethroplasty is prefer- able to grafting. We advocate excision of redundant or hair bearing flaps from previous urethroplasty when noted at reoperation but we spare the dorsal urethral plate when possible to allow subsequent onlay reconstruction. CONCLUSIONS Guidelines for urethral reconstruction after failed anterior urethroplasty are predicated on stricture length, location and severity. Circular fasciocutaneous flap urethroplasty is ex- tremely versatile and effective for long or distal refractory strictures. End-to-end urethroplasty with stricture excision is highly reliable for less extensive bulbar strictures for which previous operative repair has failed. Grafts are best used selectively in the reoperative setting. REFERENCES 1. Rosen, M. A,, Nash, P. A,, Bruce, J. E. and McAninch, J. W.: The actuarial success rate of surgical trcatmcnt of urethral stric- tures. J. Urol., part 2, 151: 360A. abstract 529, 1994. 2. Mundy, A. R.: Results and complications of urcthroplasty and its future. Brit. J. Urol., 71: 322, 1993. 3. Jordan, G. H. and Schlossberg, S. M.: “Salvage” anterior urethral reconstruction, using an epilated midline longitudinal genital skin island based on a dartos fascia1 flap. J. Urol., part 2, 151: 359A, abstract 527, 1994. 4. Roehrborn, C. G. and McConnell, J. D.: Analysis of factors con- tributing to success or failure of 1-stage urethroplasty for urethral stricture disease. J. Urol., 151: 869, 1994. 5. Jakse, G. and Marberger, H.: Excisional repair of urethral stric- ture. Follow-up of 90 patients. Urolom. 27: 233, 1986. 6. 7. 8. 9. 10. 11. 12. Morey, A. F. and McAninch, J. W.: Ultr&ound evaluation of the male urethra for assessment of urethral stricture. J. Clin. Ultrasound, 24 473, 1996. Nash, P. A., McAninch, J. W., Bruce, J. E. and Hanks, D. K.: Sono-urethrography in the evaluation of anterior urethral strictures. J. Urol., 154: 72, 1995. Barbagli, G. Selli, C. and Tosto, A,: Reoperative surgery for recurrent strictures of the penile and bulbous urethra. J. Urol., 156 76, 1996. Wessels, H. and McAninch, J. W.: Use of free grafts in urethral stricture reconstruction. J. Urol. 155: 1912, 1996. Morey, A. F. and McAninch, J. W.: When and how to use buccal mucosa grafts in adult bulbar urethroplasty. Urology, 48 194, 1996. McAninch, J. W.: Reconstruction of extensive urethral stric- tures: circular fasciocutaneous penile flap. J. Urol.. 149 488. 1993. Schlossberg, S. M., Secrest, C. L. and Jordan. G H.: Excision and  RECONSTRUCTION OF FAILED ANTERIOR URETHROPLASTY 1387 primary anastomosis for the treatment of anterior urethral strictures. J. Urol., part 2, 149 505A, bstract 1168, 993. 13. Webster, G. ., Koefoot, R. B. and Sihelnick, S. A,: Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection. J. Urol., 134: 892, 1985. 14. Morey, A. F. and McAninch, J. W.: Role of preoperative sono- urethrography for bulbar stricture reconstruction. J. Urol., in press. 15. Schreiter, F. and Noll, F.: Mesh graR urethroplasty using split thickness skin graft or foreskin. J. Urol., 142 1223, 1989. 16. Carr, L. K., acDiarmid, S. A. and Webster, G. D.: Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty. J. Urol., 157 104, 997. 17. Badlani, G. H., ress, S. M., Defalco, A., Oesterling, J. E. and Smith, A. D.: UroLume endourethral prosthesis for the treat- ment of urethral stricture disease: long-term results of the North American Multicenter UroLume Trial. Urology, 45 46, 1995. 18. Milroy, E. and Allen, A.: Long-term results of UroLume urethral stent for recurrent urethral strictures. J. Urol., 155 04,1996.
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