Principles of urethral reconstructive surgery

1. Principles of Urethral Reconstructive Surgery
By
Mohammed A. Abdel-Rassoul, M.D., M.R.C.S., F.E.B.U.
Cairo university

2. Principles of Urethral
Reconstructive Surgery
General reconstructive considerations
Urethral stricture pathology
Urethroplasty principles
Useful urethral reconstructive tools

3. General Reconstructive
Considerations

4. Many techniques in reconstructive surgery require
"tissue transfer" i.e. movement of tissue for
purposes of reconstruction.
Essential knowledge:
Anatomy of the donor and the
recipient sites
Principles that allow the tissue to
survive after transfer
General Reconstructive Considerations

5. Skin• Largest organ in the body.
• Consists of:
• Epidermis :
• Keratinocytes (mainly)
• Melanocytes
• Langerhans’ cells
• Merkel mechanoreceptor cells.
• Dermis :( 95% skin thickness)
• 2 layers:
• papillary dermis
• reticular dermis
• It is made up of
• collagen fibers
• elastin
• ground substance
• Skin appendages such as hair follicles and glands
(sweat, sebaceous and apocrine)

6. Blood supply to the skin :
six plexuses ( arise from the deep system of the main arterial
tree):
1. Subepidermal
2. Dermal
3. Subdermal (main bl. Supply to skin)
4. Subcutaneous
5. Prefascial
6. Subfascial (e.g. Fasciocutaneous, musculcutaneous)
Skin

7. Skin

8. Relaxed Skin Tension Lines (RSTL):
• orientation of collagen & elastin fibers in
dermis
• allows for minimal scar.
Lines of Maximum Extensibility (LME) or Stretch:
• perpendicular to the RSTL
• tension on wound edges best cosmesis.
Skin

9. A graft is a unit of tissue with no definite blood supply that relies on the wound bed for nutrition.
2 types:
full thickness skin grafts (FTSG)
split thickness grafts (SSG).
Skin Grafts

10. Skin & Buccal Mucosal Grafts

11. Graft “take” occurs through:
• Adherence (immobilization)
• Imbibition (48 h)
survives by passive diffusion of nutrients & waste products
into graft bed.
temperature of the graft is less than the core body
temperature
• Inosculation (72 h)
true microcirculation is reestablished in the graft.
temperature of the graft increases to core body temperature.
• Remodeling (months)
Grafts

12. Contraindications:
avascular bed (so, debride the wound
bed adequately)
infection (so, exclude microbial
infection)
malignancy
Grafts

13. Grafts

14. Typically, grafts are 0.25–0.5
mm thick
placed as a sheet, perforated
or meshed (to expand surface
area)
Mesh ratios range from 1:1 to
6:1
Grafts

15. 2-layer Dressing:
non-adherent layer, gauze
adherent dressing to reduce sheer.
The graft is checked at 2–5 days
Grafts

16. Causes of graft failure:
Seroma or hematoma formation
(lifting up the graft off the recipient
site)
Infection (second commonest cause)
Shearing/lack of adequate
immobilization
Grafts

17. Skin Flaps
A flap is a unit of tissue that can be mobilized on its own blood supply and intrinsic
circulation or can have its intrinsic blood supply reestablished via microscopic techniques.
Flaps can be subdivided according to:
1- Blood supply:
a. Random
b. Axial.
2- Flap movement:
a. Local (pivot/advancement)
b. Island
c. Free.

18. Local Skin Flaps
Local flaps are supplied by the subdermal plexus
of blood vessels in a random pattern.
used to cover adjacent defects, even when the
wound bed is ischemic & unable to sustain a graft.
They are described through their geometry

19. Advancement flap
Local Skin Flaps

20. V-Y advancement flap
Local Skin Flaps

21. Rotation flaps
Local Skin Flaps

22. Z-plasty
Local Skin Flaps

23. Multiple Z-plasty
Local Skin Flaps

24. Urethral stricture pathology

25. Pathology of anterior
Urethral stricture

26. Urethroplasty principles

27. Urethral Stricture
Open surgical repair dramatically
changed in last 50 y.
Reconstructive urologist must be familiar with the use
of numerous surgical reconstructive techniques to
deal with unexpected intraoperative situations.
Open urethroplasty is the gold standard treatment of
urethral strictures (# reconstructive ladder)

28. Now, >90% urethral strictures (regardless of
length) can be reconstructed in a one-stage
operation
Normal penis, penile skin, urethral
plate, corpus spongiosum, & Dartos
fascia
Urethral Stricture

29. Staged approach : only in small proportion of
patients
Severely scarred or insufficient local
tissues (e.g. Completely obliterated
urethral lumen, after chordee
release...)
associated skin infections / disease
Complex strictures &/or fistulae
Urethral Stricture

30. Preoperative Assessment
• Adequate & accurate preoperative information
about anatomy of the urethral stricture.
• Number
• Location
• Length
• Diameter
• Density

31. • Evaluation:
• Uroflowmetry:
• Qmax and voided volume (at least 150mL)
• Shape of the curve (flat plateau are typical of
a urethral stricture)
• U/S:
• Upper tract
• bladder
• PVR
• bladder wall thickness (chronicity of outlet
obstruction)
• Retrograde urethrography & VCUG
Preoperative Assessment

32. Timing of Surgery
Before any urethroplasty stricture should be stable & no
longer contracting
Urethra not be instrumented for 3 mo before any
planned surgery.
If urinary retention place a percutaneous suprapubic tube
After prev. failed urethroplasty wait at least 6 m before
attempting repair (for tissues to be soft & pliable and for tissue
planes to reform)
For the long stricture, it is important that the genital skin is not
infected with candidiasis or similar skin disease (penile skin that is
often used as an onlay flap for long strictures)

33. Positioning
Lithotomy position (Exaggerated in PFUI)
The patient’s legs should be liberally and carefully padded, especially
the lateral thigh to prevent peroneal nerve injury and palsy.

34. Intra-operative considerations
Intraoperative Endoscopy
useful for confirming or clarifying urethrography findings
visually assess urethral mucosa and associated scarring.
Antegrade cystoscopy can be performed.
guidewire or ureteric catheter can be placed retrograde into the
bladder.
Preferably, after urethrotomy, cystoscopy of proximal & distal ends
of the urethra (2ry stricture, stone or tumor, assess the quality &
color of the remaining urethra).
Incision
midline perineal incision , or Lambda incision

35. Urethral Mucosal Staining
Urethral injection of methylene blue to stain
the mucosa to facilitate proper suturing of
mucosa to mucosa.
Urethral Vascular Control
Esp. in EPA, cut ends of urethra bleed
aggressively noncrushing straight
“bulldog” vascular clamps
Intra-operative considerations

36. Bipolar Electocautery
Better than monopolar
Urethral Mobilization
Penile urethra is typically adherent to the corpora cavernosa
Sharp dissection
Bulbar urethra:
Bulbospongiosus m. fibers Sharply in
midline, then bluntly off the bulb
For a tension-free anastomosis overlap by
2cm (one cm spatulation each end)
Intra-operative considerations

37. Straightening the Urethra
(Shortening the Gap) Esp. in
posterior urethroplasty.
Cutting the triangular
ligament
Splitting the crura
Performing inferior
pubectomy
Re-routing the urethra
around the superior pubic
ramus.
Intra-operative considerations

38. Techniques of
Urethroplasty
Single-Stage:
1. Anastomotic Urethroplasty (EPA, EEA)
2. Substitution Urethroplasty
• Augmented Anostomtic urethroplasty (dorsal
graft or flap)
• Excision & dorsal graft + ventral flap or graft
• Incision (ventral or dorsal or lateral) and patch
the defect with an onlay graft or flap.
Staged Urethroplasty

39. Anastomotic Urethroplasty
Whenever possible, anastomotic urethroplasty is the preferred
method of urethral reconstruction, (high success rate & durability)
Indications: Bulbar strictures (proximal to the suspensory
ligament), < 2.5cm in length.
In penile urethra (distal to the suspensory ligament) risk
of chordee & better avoided.
if very proximal bulbar stricture. > 2.5cm stricture
can often be bridged.
Tension-free anastomosis is the key to successful anastomosis

41. Vascular anatomy of corpus spongiosun

42. Substitution
Urethroplasty
When the stricture is too long for stricture
excision and primary anastomosis, a patch graft or
flap of substitute material is interposed.
Buccal mucosal graft vs local penile flap?

43. Preferred Instruments

44. Head lamp (esp. proximal bulbar & perineum)
Loupe magnification glasses (2.5-4.5 x)

45. Stevens Tenotomy scissors, 6”

46. Turner Warwick Retractor

47. 4 Adson toothed forceps

48. Oral retractor

49. THANK YOU