Free-flap urethroplasty for a complex, long-segment stricture of the bulbomembranous urethra

The penis transposed to the perineum with penile-prostatic anastomotic urethroplasty for the treatment of a long segment complex urethral strictures

Background

To present our experience of transposing the penis to the perineum, with penile-prostatic anastomotic urethroplasty, for the treatment of complex bulbo-membranous urethral strictures.

Methods

Between January 2002 and December 2018, 20 patients with long segment urethral strictures (mean 8.6 cm, range 7.5 to 11 cm) and scarred perineoscrotal skin underwent a procedure of transposition of the penis to the perineum and the penile urethra was anastomosed to the prostatic urethra. Before admission 20 patients had unsuccessful repairs (mean 4.5, range 2 to 12); five patients were associated urethrorectal fistula; 16 patients reported severe penile erectile dysfunction (PED) or no penile erectile at any time and four reported partial erections.

Results

The mean follow-up period was 45.9 (range 12 to 131) months. Nineteen patients could void normally with a mean Qmax of 22.48 (range 15.6 to 31.4) mL/s. One patient developed postoperative urethral stenosis. After 1 to 10 years of the procedure, nine patients underwent the second procedure. Of the nine patients, four underwent straightening the penis and one-stage anterior urethral reconstruction using a penile circular fasciocutaneous skin flap, and five underwent straightening the penis and staged Johanson urethroplasty. Seven patients could void normally, one developed urethrocutaneous fistula and one developed urethral stenosis.

Conclusions

Transposition of the penis to the perineum with pendulous-prostatic anastomotic urethroplasty may be considered as a salvage option for patients with complex long segment posterior urethral strictures.

Overview of surgical techniques in gender-affirming genital surgery

Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Peri-operative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.

Keystone Flaps in Urethroplasty: Reconstruction in a Complex Case of Panurethral Stricture Disease

Panurethral strictures are a surgical challenge for a reconstructive urologist more so in situations where local tissue for reconstruction is deficient. Two-stage urethroplasty is the preferred option in such cases. In some complex stricture diseases where patients are not willing for multiple procedures, permanent perineal urethrostomy can give a good functional outcome. Keystone flaps have been used as a simple and effective method of wound closure in other areas of the body that would otherwise have required complex flap closure and skin grafting. We describe, for the first time, a case of inflammatory panurethral stricture disease complicated by Fournier gangrene with extensive penile, scrotal, and perineal skin deficit managed with a perineal urethrostomy, with the help of keystone design perforator island flaps with successful outcome.

Current concepts in the management of pelvic fracture urethral distraction defects

OBJECTIVES

Pelvic fracture urethral distraction defect (PFUDD) may be associated with disabling complications, such as recurrent stricture, urinary incontinence, and erectile dysfunction. In this article we review the current concepts in the evaluation and surgical management of PFUDD, including redo urethroplasty.

MATERIALS AND METHODS

A PubMed™ search was performed using the keywords "pelvic fracture urethral distraction defect, anastomotic urethroplasty, pelvic fracture urethral stricture, pelvic fracture urethral injuries, and redo-urethroplasty." The search was limited to papers published from 1980 to March 2010 with special focus on those published in the last 15 years. The relevant articles were reviewed with regard to etiology, role of imaging, and the techniques of urethroplasty.

RESULTS

Pelvic fracture due to accidents was the most common etiology of PFUDD that usually involved the membranous urethra. Modern cross-sectional imaging, such as sonourethrography and magnetic resonance imaging help assess stricture pathology better, but their precise role in PFUDD management remains undefined. Surgical treatment with perineal anastomotic urethroplasty yields a success rate of more than 90% in most studies. The most important complication of surgical reconstruction is restenosis, occurring in less than 10% cases, most of which can be corrected by a redo anastomotic urethroplasty. The most common complication associated with this condition is erectile dysfunction. Urinary incontinence is a much rarer complication of this surgery in the present day.

CONCLUSIONS

Anastomotic urethroplasty remains the cornerstone in the management of PFUDD, even in previously failed repairs. Newer innovations are needed to address the problem of erectile dysfunction associated with this condition.

Long anterior urethral reconstruction using a jejunal free flap

We report the case of a transgender patient who was referred to our department for management of chronic strictures of his neophalloplasty. We successfully used a free jejunal flap for a long anterior urethral reconstruction. He achieved a patent and functional urethra with satisfactory urinary control and was happy with the cosmetic outcome.

Reconfigured sigmoid colon neourethra: substitution of refractory posterior urethral stricture

The repair of extensive posterior urethral stricture often poses a therapeutic dilemma, especially when the urethral defect is too extensive to be repaired with traditional methods and the stricture portion has a poor blood supply. This report details the successful substitution of an extensive posterior urethral stricture using a reconfigured sigmoid colon neourethra.

Urethral substitution using an intestinal free flap: a novel approach

PURPOSE

Patients who have extensive stricture disease, those in whom hypospadias repair fails and those who sustain significant urethral trauma pose a reconstructive challenge for genitourinary surgeons. We developed an additional reconstructive option for men with a severely diseased urethra when grafting procedures and local tissue flaps have failed or are otherwise contraindicated.

MATERIALS AND METHODS

A genitourinary reconstructive team performed novel intestinal free flap substitution urethroplasty in 2 patients. A segment of jejunum is harvested on a vascular pedicle and plicated into an appropriate size urethral substitute. Microvascular anastomoses allow this segment to remain viable and functional. The technical aspects of repair and surgical considerations are detailed.

RESULTS

The 2 patients have a satisfactory functional and cosmetic outcome. At short followup the urethral lumen remained patent and the intestinal urethra remained viable and intact. Both patients have good urinary streams and are able to void in the standing position.

CONCLUSIONS

This initial experience in 2 patients indicates that intestinal segment urethral substitution may be considered within the reconstructive armamentarium of genitourinary surgeons when more conventional options have failed or are contraindicated. Continued vigilant followup is necessary to detail any secondary complications. In addition, further experience with this technique by other surgeons would help determine its overall usefulness.