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Surgical Tips and Tricks During Urethroplasty for Bulbar Urethral Strictures
Focusing on Accurate Localisation of the Stricture: Results from a Tertiary
Centre

Article  in  European Urology · January 2015

DOI: 10.1016/j.eururo.2014.12.029 · Source: PubMed

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Surgery in Motion

Surgical Tips and Tricks During Urethroplasty for Bulbar Urethral

Strictures Focusing on Accurate Localisation of the Stricture:
Results from a Tertiary Centre

Tricia L.C. Kuo *, Suresh Venugopal, Richard D. Inman, Christopher R. Chapple

Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK

Article info Abstract

Article history: Background: There are several techniques for characterising and localising an anterior
Accepted December 13, 2014 urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and
endoscopy. However, these techniques have some limitations. The final determinant is
intraoperative assessment, as this yields the most information and defines what surgical
Keywords: procedure is undertaken.
Urethral stricture Objective: We present our intraoperative approach for localising and operating on a
Operative technique urethral stricture, with assessment of outcomes.
Design, setting, and participants: A retrospective review of urethral strictures operated
Urethroplasty
was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All
patients were referred to a tertiary centre and operated on by two urethral reconstruc-
Please visit tive surgeons.
Surgical procedure: Intraoperative identification of the stricture was performed by
www.europeanurology.com and cystoscopy. The location of the stricture is demonstrated externally on the urethra
www.urosource.com to view the by external transillumination of the urethra and comparison with the endoscopic
accompanying video. picture. This is combined with accurate placement of a suture through the urethra,
at the distal extremity of the stricture, verified precisely by endoscopy.
Outcome measures and statistical analysis: Clinical data were collected in a dedicated
database. Intraoperative details and postoperative follow-up data for each patient were
recorded and analysed. A descriptive data analysis was performed.
Results and limitations: A representative group of 35 male patients who had surgery
for bulbar stricture was randomly selected from January 2010 to December
2013. Mean follow-up was 13.8 mo (range 2–43 mo). Mean age was 46.5 yr (range
17–70 yr). Three patients had undergone previous urethroplasty and 26 patients had
previous urethrotomy or dilatation. All patients had preoperative retrograde ure-
thrography and most (85.7%) had endoscopic assessment. The majority of patients
(48.6%) had a stricture length of >2–7 cm and 45.7% of patients required a buccal
mucosa graft. There were no intraoperative complications. Postoperatively, two
patients had a urinary tract infection. All patients were assessed postoperatively
via flexible cystoscopy. Only one patient required subsequent optical urethrotomy
for recurrence.
Conclusions: Our intraoperative strategy for anterior urethral stricture assessment
provides a clear stepwise approach, regardless of the type of urethroplasty eventually
chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ven-
tral, or augmented roof strip). It is useful in all cases by allowing precise localisation of
the incision in the urethra, whether the stricture is simple or complex.

* Corresponding author. Department of Urology, Singapore General Hospital, Outram Road,

Singapore 169608, Singapore. Tel. +65 81231004.
E-mail address: [email protected] (T.L.C. Kuo).

http://dx.doi.org/10.1016/j.eururo.2014.12.029
0302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
 EUROPEAN UROLOGY 67 (2015) 764–770 765

Patient summary: We studied the treatment of bulbar urethral strictures with different
types of urethroplasty, using a specific technique to identify and characterise the length of
the stricture. This technique is effective, precise, and applicable to all patients undergoing
urethroplasty for bulbar urethral stricture.
# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

1. Introduction At our institution, we often ask patients on intermittent self-

dilatation (ISD) to stop this procedure a couple of weeks before surgery.
Another urethrogram after ISD cessation and just before surgery can also
The surgical technique used for anterior urethroplasty
aid in assessing stricture length.
depends on several key factors. These include the char-
acteristics of the stricture, patient comorbidities, urethral
2.2.2. Perioperative endoscopic evaluation and placement of a guide
and penile length, and surgeon preference. Stricture
wire
characteristics that influence the type of reconstruction A rigid cystoscope is inserted into the urethra for visualisation of the
include stricture length, degree of spongiofibrosis, anatomic junction between healthy pink mucosa and the abnormal white
position, aetiology, and previous treatment. Most means of appearance of spongiofibrosis. This aids in localisation of the stricture.
assessment are preoperative, such as radiologic (retrograde A guide wire passed through the stricture (Fig. 2) facilitates later
urethrogram, RUG), ultrasonographic, and endoscopic dissection and identification of the urethral lumen. The guide wire is
(cystoscopy and urethroscopy) methods, and can be secured to the foreskin with a silk tie to prevent displacement.
difficult to interpret and relate to operative findings. The
above techniques are useful, but ultimately the reconstruc- 2.2.3. Perineal dissection
tion is based on intraoperative findings. A vertical midline perineal incision is used. After incision of the Colles
We present here our technique for precise intraoperative fascia, a ring retractor is placed and yields excellent exposure. The
bulbospongiosus muscle is divided and retracted laterally to expose the
assessment of an anterior urethral stricture during ure-
urethra. The urethra is circumferentially mobilised. Further mobilisation
throplasty, and a retrospective review of outcomes for a
along the urethral length proximally and distally allows for later tension-
representative group of patients.
free anastomosis/augmentation.

2. Patients and methods 2.2.4. Localisation and characterisation of the stricture

Passage of a metal sound through the tight stricture to the proximal
2.1. Study population extent is unwise since this dilates the stricture and may cause urethral
trauma, which makes identification of the stricture site difficult. In fact,
Data were retrospectively collected from the medical records for a
representative group of 35 patients who underwent bulbar or
bulbomembranous urethroplasty at a tertiary centre. Our centre carries
Table 1 – Patient demographics, clinical presentation, and
out more than 100 urethroplasties a year. A heterogeneous representa-
previous interventions and treatment
tive cohort was selected to show the flexible application of our surgical
technique. All patients were operated on by two dedicated urethral Parameter Value
reconstructive surgeons between January 2010 and December 2013. All
Patients (n) 35
patients were extensively counselled on surgical and anaesthetic risks.
Mean age, yr (range) 46.5 (17–70)
Informed consent was obtained.
Mean follow-up, mo (range) 13.8 (2–43)
Preoperative assessment included medical history, physical exami- Clinical presentation, n (%)
nation, and routine laboratory evaluation. All patients underwent Retention 12 (34.2)
preoperative retrograde urethrography and 30 patients (85.7%) had Obstructive symptoms 24 (68.6)
endoscopic assessment. Endoscopic evaluation was only performed in (eg, poor stream,
dribbling, hesitancy,
selected cases in which the RUG was not clear.
incomplete emptying)
Patient demographics, symptoms at presentation, and history of
Storage symptoms 2 (5.7)
previous interventions and treatment are shown in Table 1. Pain 6 (17.1)
Urinary tract infection 4 (11.4)
2.2. Surgical technique Haematuria 4 (11.4)
Possible cause, n (%)
History of lichen sclerosis 5 (14.2)
2.2.1. Preoperative preparation and patient positioning
Trauma 3 (8.6)
Under general anaesthesia with broad-spectrum antibiotic cover, the
Previous endoscopic 11 (31.4)
patient is placed in a lithotomy position, with the legs flexed at 308. procedure (eg, transurethral
Trendelenburg tilting (head down) of the patient facilitates later radical prostatectomy,
dissection. Routine thromboembolic prophylaxis with compression cystoscopy)
stockings and compressive leg devices is used in all cases. Previous catheterisation 4 (11.4)
A preoperative RUG for a representative patient shows a bulbar Previous treatment/intervention, n (%)
Urethroplasty 3 (8.6)
stricture and slight narrowing at the mid-penile urethra (Fig. 1). Flexible
Optical urethrotomy or dilatation 27 (77.1)
cystoscopy and urethroscopy revealed that the area in the penile urethra Intermittent self-dilatation 10 (28.6)
was simply a mucosal fold.
766 EUROPEAN UROLOGY 67 (2015) 764–770
[(Fig._1)TD$IG]
incision into the lumen of the stricture is facilitated by positioning of stay
sutures through the full thickness of the urethra. These stay sutures allow
rotation of the urethra, whether for a ventral, dorsal, or laterally positioned
augmentation. If a guide wire is in place, the lumen can be clearly identified
and the urethra opened proximally through the stricture until normal
urethra is reached, thereby identifying the location, length, and extent of
the spongiofibrosis. It is then possible to plan the reconstructive
procedure, whether anastomotic (disconnected or Heineke-Mikulicz) or
augmentation (dorsal, ventral, or augmented roof strip).
The length of the stricture is measured with a tapeline when
considering augmentation. The factors that determine whether the
stricture length can be overcome with an anastomotic approach are the
Fig. 1 – Retrograde urethrogram showing a tight bulbar urethral experience of the surgeon and the anatomy of the patient [1].
stricture.
As a rule, the urethra is calibrated at 32F proximally and 28F distally
in uncomplicated cases. This arbitrarily calibrates the size of the lumen
and allows subsequent passage of surgical instruments such as
cystoscopes.
patients are often asked to halt intermittent self dilatation for 1–2 wk
before surgery for the same reason.
With severe stenosis and retention, there is often a suprapubic 2.2.6. SPC placement
catheter (SPC) present. The surgeon may then pass a flexible cystoscope Before closure of the urethra, an SPC is placed in all patients. We
or metal sound via the suprapubic tract. However, in the absence of a SPC recommend use of an SPC in our patients, as they usually travel some
and tract, the distal extent of the stricture can easily be visualised with a distance and it provides a safety measure. In addition, an SPC allows
transurethral cystoscope. This is identified externally by transillumina- instillation of contrast for subsequent voiding cystourethrograms. The
tion of the urethra. Transillumination may be challenging on approach- contrast can be voided around the urethral catheter.
ing the posterior urethra. However, once the urethra is suitably exposed, A Turner-Warwick Hey Groves urethral staff is placed via the open
then it is usually possible to identify the stricture on the dorsal aspect. perineal wound into the urethra and passed into the bladder, as shown in
A stay suture may be placed at the distal extent. This can easily be Figure 4A. A cut in the skin in the suprapubic region is made to allow
accomplished with the assistant holding the cystoscope and the surgeon the emergence of the metal tip of the staff. A nylon stitch is tied to a 16F
compressing the exposed urethra to verify the exact spot. The suture Foley catheter (Fig. 4B). The SPC is brought down into the bladder by
traverses the ventral aspect of the urethra through the entire thickness of simply pulling back on the staff (Fig. 4C). Cystoscopy is then performed
the urethra into the lumen at the precise junction between normal to push the SPC into the bladder for direct visualisation of the catheter
mucosa and the diseased stricture. This can be verified by direct balloon in the bladder. A clip is used to secure the long end of the nylon
visualisation both through the cystoscope and externally (Fig. 3). stitch. Then the long end of the nylon stitch is tied to a single 14F-lumen
With this suture in place, the surgeon is then able to fully assess the Porges urethral catheter, introduced from the penile urethra (Fig. 4D).
position of the stricture. Use of a suture allows accurate incision of the The nylon stitch is secured to the suprapubic region with beads and
stricture. The suture is placed within 1 mm of the stricture, and any small metallic clamps (Fig. 4E). The urethral catheter is therefore
potential trauma to this is absorbed on subsequent spatulation. This attached to a suture quite separate from the SPC.
approach is less harmful than incising in the wrong place. Using this method, it is rare for a urethral catheter to be dislodged in
our experience. The placement of the SPC and urethral catheter on a
2.2.5. Stricturotomy and decision-making process nylon suture also means that there is no inflated balloon to disrupt the
The stricture is opened either laterally or dorsally between the 9- and anastomosis.

[(Fig._2)TD$IG]
3-o’clock positions where the corpus spongiosum is thinnest. This
2.2.7. Dressings and securing the catheters
The layers of the perineal wound are closed carefully to eliminate any
dead space and prevent haematomas. We do not routinely place a drain.
A compression dressing is applied with wool and molyknickers. Finally,
both catheters are taped to the anterior abdominal wall to prevent
dislodgement and pulling on the wound during recovery.

2.3. Postoperative course

A standard postoperative protocol is used in all cases. Intravenous broad-

spectrum antibiotics are continued for 3 d. Thereafter, patients are given
oral antibiotics until the catheters are removed. Patients are ambulated
on postoperative day 1. Compressive dressings are kept in place for 4 d.
Previously, patients were admitted for 2 wk. However, we have since
modified our protocol and now they are discharged on the fourth
postoperative day.

2.4. Postoperative follow-up

The patient is brought back 2 wk later for a postoperative urethrogram

Fig. 2 – A guide wire is placed through the stricture. via the SPC. If there are no leaks, the urethral catheter is then removed
 EUROPEAN UROLOGY 67 (2015) 764–770 767
[(Fig._3)TD$IG]

Fig. 3 – (A) Stay sutures visualised endoscopically after (B) placement at the distal end of the stricture. (C) Transillumination of the urethra to show the
site of the stricture (yellow arrow).

and the SPC is closed with a spigot. Once the patient is voiding well with for recurrence. On follow-up with flexible urethroscopy,
acceptable residual volumes, the SPC is removed. three patients had a paper-thin diaphragm or web at the
Subsequent follow-up is conducted at 6 wk, 3 mo, 6 mo and 1 yr anastomotic junction. This was not a recurrence or
postoperatively and involves flexible urethroscopy.
restricture and was easily treated with either dilatation
under local anaesthesia or endoscopic incision under
2.5. Data analysis general anaesthesia if the patient could not tolerate the
discomfort. These diaphragms or webs did not recur
Clinical data were collected in a dedicated database. Intraoperative subsequently and were most likely due to local healing.
details and postoperative follow-up data for each patient were recorded
and analysed. A descriptive data analysis was performed.
4. Discussion

3. Results The reconstructive surgical technique for urethroplasty

is unpredictable. Success depends on the ability of the
Intraoperative findings are listed in Table 2. The majority of surgeon to adopt or adapt procedures according to findings
patients had a stricture length of >2–7 cm and 45.7% of
patients required buccal mucosa graft. There were no
intraoperative complications. In all substitution/augmenta- Table 2 – Intraoperative findings and results
tion cases, buccal mucosa was used. In addition, all grafts
Parameter Patients, n (%)
were placed dorsally. This technique was popularised by
Barbagli et al [2] and is a modification of the Monseur Stricture length
<1 cm 1 (2.9)
technique [3]. We advocate dorsal or lateral placement of the
1–2 cm 16 (45.7)
graft, as that is where the corpus spongiosum is thinnest. 2–7 cm 17 (48.6)
Concomitant procedures included correction of chordee >7 cm 1 (2.9)
for one patient and glanduloplasty for another. Urethroplasty technique
Anastomosis 19 (54.3)
Two patients had a postoperative urinary tract infection. Substitution/augmentation 16 (45.7)
Only one patient required subsequent optical urethrotomy
768 EUROPEAN UROLOGY 67 (2015) 764–770
[(Fig._4)TD$IG]

Fig. 4 – Suprapubic catheter placement.

noted during the course of the operation. This is the so- and voiding cystourethrogram should also be carried out,
called TITBAPIT principle of reconstructive surgery—take it the latter to better define the proximal limit of the stricture
to bits and put it together [4]. and assess the external sphincter complex and bladder
A RUG is the standard preoperative investigation for neck. However, it is well known that these radiographic
further delineation of a stricture. A consecutive ascending studies often underestimate stricture length because they
 EUROPEAN UROLOGY 67 (2015) 764–770 769

are performed in an oblique position in relation to the We acknowledge that our review is retrospective.
anteroposterior x-ray beam, resulting in a shorter projected However, it is difficult to carry out randomised controlled
view of the stricture [5,6]. In addition, in the case of very trials in a heterogeneous clinical group of patients. Our
tight strictures, chronic high-pressure voiding results in main intent in this paper was to focus on the surgical
dilatation of the proximal segment. This segment is technique. Equipment and facilities may be an issue in some
therefore also abnormal, so the stricture appears to be centres, and this is a caveat to our technique.
shorter than it really is. Hence, RUG is limited in its ability to Terminology and standardisation previously agreed and
accurately reveal urethral stricture length, and the location published as a consensus statement [14] and as guidelines
or extent of periurethral disease [5–7]. by the International Consultation on Urological Diseases
In view of the limitations of radiological evaluation, some after the Société Internationale d’Urologie meeting in
have proposed ultrasonographic evaluation. In addition to October 2010 were adhered to in this article [15].
ascertaining the stricture length and location, ultrasound can Reconstructive urology requires application of a set of
also provide information regarding the degree of spongiofi- well-defined techniques used in an appropriate sequence
brosis and concomitant pathology, such as diverticulae, depending on findings at the time of surgery. The sequence
fistulae, stones, false passages, and periurethral abscesses used will depend on what is found after the urethral
[5,6,8]. Retrospective reviews have shown that intraopera- stricture has been clearly characterised.
tive ultrasound changed the surgical approach in 19% of
cases, and was integral in deciding between two possible 5. Conclusions
approaches for 26% of patients [9]. However, interpretation of
ultrasonography of the urethra is also operator-dependent In summary, our intraoperative approach and strategy for
and results may vary between individuals. Therefore, anterior urethral stricture assessment provide a clear
ultrasonography should be an adjunct investigational tool stepwise guide, regardless of which type of urethroplasty
and cannot replace a formal intraoperative assessment. is eventually chosen (anastomotic or augmentation, dorsal
The feasibility of performing Heineke-Mikulicz or discon- or ventral, or augmented roof strip). In this paper and video,
nected primary anastomosis versus augmentation urethro- we clearly identify the steps to characterise a stricture and
plasty depends on the stricture characteristics. Hence, subsequently reconstruct it.
precise anatomic knowledge of the stricture is essential,
and is critical in allowing a borderline length stricture of
<2.3–3.0 cm to be treated anastomotically rather than by Author contributions: Tricia L.C. Kuo had full access to all the data in the
augmentation, as the latter has a lower long-term success study and takes responsibility for the integrity of the data and the
rate. Ideally, the feasibility is assessed and predicted accuracy of the data analysis.
preoperatively as far as possible, but this is often not possible Study concept and design: Kuo, Venugopal, Inman, Chapple.
because of the limitations of radiological investigations. In all Acquisition of data: Kuo, Venugopal.
cases, intraoperative assessment and localisation are the final Analysis and interpretation of data: Kuo, Venugopal, Inman, Chapple.
determinants of how a stricture is reconstructed. Drafting of the manuscript: Kuo, Venugopal, Inman, Chapple.
An alternative and ingenious method of delineating the Critical revision of the manuscript for important intellectual content: Kuo,
proximal extent of a stricture is the use of a small 4–5F Venugopal, Inman, Chapple.
Fogarty vascular catheter as an alternative to a guide wire. Statistical analysis: Kuo, Venugopal, Inman, Chapple.
The balloon catheter acts as an intraluminal guide and can Obtaining funding: None.
Administrative, technical, or material support: Kuo, Venugopal, Inman,
be inflated to the desired balloon size (eg, 30F) in the
Chapple.
proximal lumen [10].
Supervision: Kuo, Venugopal, Inman, Chapple.
The surgical tips and tricks described here using a
Other: None.
consecutive approach have several advantages compared
to existing strategies of cutting down on a sound. There is Financial disclosures: Tricia L.C. Kuo certifies that all conflicts of interest,
precise visual demarcation of the junction between including specific financial interests and relationships and affiliations
abnormal and normal mucosa. This is particularly applica- relevant to the subject matter or materials discussed in the manuscript
(eg, employment/affiliation, grants or funding, consultancies, honoraria,
ble to treatment of recurrent strictures. Multiple previous
stock ownership or options, expert testimony, royalties, or patents filed,
endoscopic manipulations and treatment are associated
received, or pending), are the following: None.
with a more difficult definitive open repair and a
potentially poorer outcome [11]. Other authors suggest Funding/Support and role of the sponsor: None.
that the failure rate is not significantly higher for patients
Acknowledgments: We are grateful to the Department of Medical
with previous endoscopic treatments undergoing open
Illustrations, Royal Hallamshire Hospital, Sheffield, UK.
surgical repairs, but the urethroplasty may be more
complex [12,13] and certainly the success rate is better
for anastomotic than for augmentation procedures. Some- Appendix A. Supplementary data
times the reason for failure of the first urethroplasty is
technical, as the surgeon does not get sufficiently proximal. The Surgery in Motion video accompanying this article can
Evidence of this can be seen in patients with recurrence at be found in the online version at http://dx.doi.org/10.1016/j.
the proximal anastomotic ring. eururo.2014.12.029 and via www.europeanurology.com.
770 EUROPEAN UROLOGY 67 (2015) 764–770

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