Cystoscopic transvesical placement of sutures for repair of posterior urethral strictures

Abstract

Successful repair of post-traumatic posterior urethral strictures can be accomplished in several ways, and careful patient selection is of utmost importance. The two most important selection factors to consider are the length of the stricture or the gap that must be bridged and whether or not the anterior urethra has been damaged. If the anterior urethra is undamaged, it, being an elastic structure, can be mobilized and used to bridge the gap. If the anterior urethra is damaged or the gap to be bridged is greater than 1.5 cm, some form of skin substitution urethroplasty should be used.’ The two main types are the posteriorly based flap of perineal or perineoscrotal skin and the scrotal “drop back” technique.2 The primary rule of urethroplasty is complete excision of all scar and reapproximation of normal urethra to normal urethra or skin substitution inlay that extends into at least 2-3 cm of overtly normal urethra.2 This frequently requires placement of sutures deep in the perineum, occasionally extending across the sphincter and into the prostatic urethra itself. Proper placement of these sutures is critical and can be difficult even when using the special curved needles and other instruments developed by Turner-Warwick.2 In difficult cases involving a small patient or an exceedingly narrow pelvis, we have simplified placement of these deep sutures by utilizing the suprapubic cystotomy tract. The loaded urethroplasty needle is passed alongside the cystoscope through the tract. The tip of the scope is passed through the bladder neck into the prostatic urethra, and the stitch is placed under direct vision in the distal prostatic urethra (Fig. 1). Proper placement and a secure “bite” are assured. An assistant grasps the suture from below under direct vision and secures Sumawbic