The Treatment of Panurethral Strictures

Abstract

Extensive or panurethral strictures that involve both the pendulous and bulbar urethra were difficult to treat surgically. Successful repair of panurethral strictures was challenging, particularly in patients with recurrent panurethral strictures after previous surgical attempts. Such therapeutic efforts were well-known risk factors for the failure of urethroplasty, because of spongiofibrosis and poor vascular supply. Such strictures were traditionally managed with 2-stage repairs using scrotal skin (1, 2). However, as the field of urethral reconstruction developed, there was a move towards 1-stage repair using free grafts made of skin, pedicle-based flaps or combined approaches (3-9). Numerous substitution urethroplasty techniques have been described and there were, however, no universally accepted graft material for either primary urethral substitution or technique of reconstruction after multiple failed attempts. (3-9). The penile skin flap provided a versatile mechanism for achieving excellent results in the single-stage repair of complex anterior urethral strictures. The distal penile circular fasciocutaneous flap (FCF) technique of urethroplasty was first reported in 1993 by McAninch (10). The flap meets all criteria for tissue transfer and urethral reconstruction. It reliably provides ample hairless tissue, usually 13 to 15 cm long (depending on penile size), flexibility, versatility, and without compromising cosmesis or function (11). In addition, the circular fasciocutaneous penile flap is easily combined with other tissue-transfer techniques when necessary, enabling one-stage reconstruction in the majority of cases. For those patients in whom genital skin was insufficient or panurethral strictures involving more than the distal bulbar urethra, alternative tissue or combined grafts urethroplasty was needed for urethral reconstruction. Wessells et al (3) reported a series of seven patients with pan-urethral strictures (mean length, 19 cm.) treated using a fasciocutaneous flap combined with buccal mucosa, bladder epithelium or skin grafts. Elliott et al (4) described nine patients who underwent distal penile fasciocutaneous flap repair of a concomitant penile urethral stricture and buccal graft reconstruction for a bulbar stricture; the repair was successful in eight of the nine patients. Berglund et al (5) reported a series of 18 patients with a mean stricture length of 15.1 cm using combined buccal mucosal graft and genital skin flap for reconstruction of extensive anterior urethral strictures. For those patients in whom no adequate donor skin was available for grafting because of multiple penile surgeries or diseased skin existing, mucosal grafts urethroplasty may be appropriate (7,8). Several experimental studies and clinical experiences have contributed to