The value of definitive perineal urethrostomy for the treatment of complex adult anterior urethral strictures

Abstract

Objective To analyze the clinical outcome of definitive perineal urethrostomy for the treatment of complex adult anterior urethral strictures. Methods From June 2012 to February 2018, 28 patients who underwent the definitive perineal urethrostomy for a complex anterior urethral stricture were retrospectively reviewed. The mean age of the patients was 62.3 (range 34 to 77) years and stricture etiology was lichen sclerosus in 46.4%(13/28) of the cases, iatrogenic stricture after transurethral resection of the prostate in 35.7%(10/28), failed hypospadias repair in 10.7%(3/28), infection 3.6%(1/28) and idiopathic etiology 3.6%(1/28). The mean stricture length was 9.6 (range 4.5 to 16.0) cm and the stricture length 10 cm in 57.1%(16/28). Of 28 patients 21 (75%) underwent prior urethral dilation, 4 (14.3%) underwent direct vision internal urethrotomy (DVIU) and 17 (60.7%) underwent urethroplasty. Among the medical history of interest, hypertension was observed in 17 patients (60.7%), chronic ischemic heart disease in 11 patients (39.3%), diabetes mellitus in 9 patients (32.1%) and chronic obstructive pulmonary disease (COPD) in 9 patients (32.1%). All patients completed the perineal urethrostomy with inverted U-shaped perineal skin flap. The patient was placed in a normal lithotomy position and an inverted U-shaped perineal incision was made. We can get an inverted U-shaped perineal skin flap after dissecting along the bulbospongiosus muscle. The bulbar urethra was opened along the ventral surface and the margins of the spongiosum tissue were closed with perineal skin flap. We analyzed the clinical characteristics of the patients, the outcome of the technique and investigated the satisfaction rates of the patients by outpatient follow-up or telephone interview. Surgical success was defined as functional voiding without the need for further procedures. Results The perioperative complications included 3 cases of urinary tract infection, 1 case of bleeding and 1 case of wound dehiscence. Mean follow-up length was 27.2(range 6.0 to 64.0)months. Of 28 cases 26 (92.9%) were successful and the mean maximum urinary flow rate was 26.5(range 17.0 to 40.0)ml/s. Postoperatively, 2 cases of urethrostomy strictures were found in 2 months and 4 months, respectively. They required periodic outpatient dilation and the younger one was in the waiting list for revision of the perineostomy and the older one refused the revision. Of 28 patients 24 (85.7%) were satisfied with the results obtained with surgery, 15 were very satisfied, 9 cases satisfied and 4 cases dissatisfied. Conclusions The successful rate of the definitive perineal urethrostomy for the complex adult anterior urethral strictures was high and patients were satisfied with the outcome of the surgery. The definitive perineal urthrostomy is a well-tolerated treatment option for patients with complex anterior urethral strictures, especially for those aged and with extensive comorbidities. Key words: Urethral stricture; Anterior urethral; Perineal urethrostomy; Urinary diversion