Penile Flap Research Articles

ERECTILE FUNCTION AFTER ANTERIOR URETHROPLASTY

We ascertained the impact of anterior urethroplasty on male sexual function. A validated questionnaire was mailed to 200 men who underwent anterior urethroplasty to evaluate postoperative sexual function. Questions addressed the change in erect penile length and angle, patient satisfaction with erection, preoperative and postoperative coital frequency, and change in erection noted by the sexual partner. Results were stratified by the urethral reconstruction method, namely anastomosis, buccal mucosal graft, penile flap and all others, and compared with those in a similar group of men who underwent circumcision only. Of the 200 men who underwent urethroplasty 152 who were 17 to 83 years old (mean age 45.7) completed the questionnaire. Average followup was 36 months (range 3 to 149). Overall there was a similar incidence of sexual problems after urethroplasty and circumcision. Penile skin flap urethroplasty was associated with a slightly higher incidence of impaired sexual function than other procedures (p >0.05). Men with a longer stricture were most likely to report major changes in erectile function and penile length (p <0.05) but improvement was evident with time in 61.8%. Overall anterior urethral reconstruction appears no more likely to cause long-term postoperative sexual dysfunction than circumcision. Men with a long stricture may be at increased risk for transient erectile changes.

URETHRAL PLATE SALVAGE WITH DORSAL GRAFT PROMOTES SUCCESSFUL PENILE FLAP ONLAY RECONSTRUCTION OF SEVERE PENDULOUS STRICTURES

A modified 1-stage penile flap onlay reconstruction is presented for patients with a long stricture in whom the urethral plate is deficient or absent. Of 37 patients who underwent transverse penile island flap onlay urethroplasty 3 men and 1 boy required simultaneous augmentation (2) or replacement (2) of an inadequate urethral plate. The 15-year-old boy had persistent severe chordee after multiple hypospadias procedures. A dorsal buccal mucosal graft was used in 3 cases and cadaveric dermal graft was used in 1. The goal of dorsal graft application in each case was to create a uniform urethral plate 1 cm. wide to promote successful 1-stage penile flap onlay reconstruction. No patient has required further instrumentation and all void without difficulty. In the 15-year-old boy chordee has completely resolved. Using dorsal grafts to salvage an inadequate urethral plate during 1-stage penile island flap onlay reconstruction obviates flap tubularization.

COMPLICATIONS RELATED TO THE HIGH LITHOTOMY POSITION DURING URETHRAL RECONSTRUCTION

We identified risk factors for complications of the lower extremities related to high lithotomy positioning during specific urethral reconstruction procedures in male patients. Records from 185 open urethroplasties were evaluated for position related complications of the lower extremities (the compartmental syndrome, rhabdomyolysis, neurapraxia). Morphometric data (patient height, weight) and surgical details (duration of surgery and lithotomy positioning, types of repair and stirrups, stricture length and location) were assessed. In the 185 patients 18 position related complications (10%) were identified, 4 of which were severe. Univariate analysis showed length of stricture, and duration of surgery and lithotomy positioning to be statistically significant risk factors (p <0.05). Height, weight, body mass index and type of stirrups did not increase risk. Anterior end-to-end anastomosis and straightforward buccal mucosa patch grafts entailed negligible risk. Longer procedures (prostatomembranous and penile skin flap repairs) had higher complication rates (12% and 22%, respectively). Beginning penile skin flap procedures with patients in the supine position during flap harvesting followed by repositioning into high lithotomy for perineal flap transfer virtually eliminated the risk of severe complications. The risk of position related complications during urethral reconstruction is directly proportional to the duration of high lithotomy positioning. Procedures of less than 5 hours in duration had minimal risk. For complex flap procedures, we perform penile flap dissection with the patient supine and reposition for perineal flap transfer.

Versatilidad del colgajo axial fasciocutáneo de piel de pene en la reconstrucción de la uretra péndula

PurposeWe describe three cases, with different feaures, of anterior urethral strictures that were treated with the same technique: a circular axial penile fasciocutaneous flap. Material and methodsWe report three cases of patients with urethral strictures that affected the whole glandar and penile urethra. In one case the stricture affected the bulbar urethra. No patient has the preputial skin disposable, because of a previous circumcision, and all has been treated with different techniques. In one patient, a first step urethroplastia was performed previously, open all the penile urethra. All the cases were successfully treated with a circular axial fasciocutaneos penile flap in one stage. In case number one the reconstruction was combined with a scrotal flap. In case number three, the glandar urethra was reconstructed. ConclusionsThe circular axial fasciocutaneos penile flap is a versatile technique that can be use to correct various type of strictures of the whole glandar and penile urethra alone or associated with strictures of the bulbar urethra.

RECONSTRUCTION OF RESISTANT STRICTURES OF THE FOSSA NAVICULARIS AND MEATUS

We evaluate the long-term efficacy of an integrated 1-stage approach for the reconstruction of resistant strictures of the fossa navicularis and meatus. In 19 men with resistant glanular urethral strictures of varied origin reconstruction was tailored to the individual characteristics of the urethral stricture and glans. Urethral reconstruction was performed with a ventral transverse island fasciocutaneous penile flap in 16 cases, resection and primary end-to-end anastomosis in 2, and a buccal mucosal graft in 1. The glanuloplasty was completed as a glans cap in 15 patients and as glans wings in 4. In the latter group the glans was significantly scarred from the causative process and previous failed procedures. The patients were followed for a mean of 42.7 months. Transient urinary splaying and mild glans torsion were observed postoperatively but resolved within 8 weeks. Overall, a durable, functional and cosmetic result was achieved in 18 patients (94.7%), and only 1 had an anastomotic stricture that required reoperation. Although the management of resistant glanular urethral strictures can be difficult, the appropriate reconstructive techniques can permanently correct these strictures. We describe a logical 1-stage approach to reconstructing the fossa navicularis and meatus, allowing a functionally successful and cosmetically appealing long-term outcome.

ROLE OF PREOPERATIVE SONOURETHROGRAPHY IN BULBAR URETHRAL RECONSTRUCTION

The accuracy of sonourethrography for the evaluation of bulbar urethral strictures has been well documented. Thus, we sought to define the role of preoperative sonourethrography in establishing objective criteria for procedure selection during bulbar urethral reconstruction. Sonourethrography was performed preoperatively, just before incision, in 67 men selected for bulbar urethroplasty. All patients had strictures 25 mm. or less in length on preoperative radiographic retrograde urethrography, thus potentially amenable to resection and end-to-end anastomosis. Ultrasonic measurements were prospectively recorded, compared with those on preoperative retrograde urethrography, and used to guide the selection of urethroplasty technique. Overall, a significant trend for retrograde urethrography to underestimate stricture length was demonstrated (r = 0.678, p < 0.0001). Indeed, sonographic measurements were frequently twice those of retrograde urethrography, occasionally more. All 26 patients with short strictures on retrograde urethrography (10 mm. or less) were successfully treated by resection and end-to-end anastomosis, and sonographic assessment did not alter management. However, ultrasonic measurement changed the reconstructive procedure selected in 15 of 41 patients (37%, 3 penile flaps, 12 graft procedures) with bulbar strictures of intermediate length on retrograde urethrography (11 to 25 mm.). Sonourethrography has a major influence on selection of therapy in patients with bulbar strictures of intermediate length. By prospectively identifying strictures too long for resection and end-to-end anastomosis, sonourethrography enables quantitative criteria for selection of patients who may be more appropriately treated by flap or graft procedures. We advocate excisional therapy for strictures appearing sonographically to be 25 mm. or less, and substitution urethroplasty for longer strictures.

Penile Circular Fasciocutaneous Flap Urethroplasty

Penile Circular Fasciocutaneous Flap Urethroplasty

Single Stage Reconstruction of Complex Anterior Urethral Strictures: Combined Tissue Transfer Techniques

Reconstruction of most urethral strictures is possible with anastomotic, graft or skin flap procedures alone. We describe the combination of tissue transfer techniques to preserve the urethral plate and reconstruct long and complex urethral strictures in 1 stage. We reviewed the results in 25 patients who underwent anterior urethroplasty requiring more than 1 tissue transfer technique to achieve urethral reconstruction in 1 stage. Outcome was excellent in 22 patients (88%). Seven patients with pan-urethral strictures (mean length 19 cm.) required a fasciocutaneous flap combined with a buccal mucosa, bladder epithelium or skin graft. A total of 13 patients with focally dense strictures underwent excision of the most severe portion of the stricture with dorsal reapproximation, thereby improving the quality of the urethral plate and allowing simultaneous flap or graft onlay reconstruction. Five patients with multiple separate strictures required a distal onlay fasciocutaneous flap with excision and end-to-end anastomosis of a separate, more proximal stricture. A thorough knowledge of the vascular supply of the urethra allowed creative application of different tissue transfer techniques, enabling 1-stage reconstruction of complex urethral strictures. An excellent outcome was achieved by preserving or revising the urethral plate and avoiding the problems associated with hair-bearing flaps and 2-stage procedures.

When and how to use buccal mucosal grafts in adult bulbar urethroplasty

Objectives To evaluate the efficacy of buccal mucosa in the repair of adult urethral stricture disease, we report our experience with its use as a nontubularized onlay graft during bulbar urethral reconstruction. Methods From June 1993 to January 1996, 75 men underwent anterior urethral reconstruction for stricture disease. Single-stage urethroplasty with an onlay patch graft of buccal mucosa was performed in 13 patients with complex, refractory strictures of the bulbar urethra. In all cases, a two-team approach was used in which one team harvested the graft from the mouth while the perineal team simultaneously exposed and calibrated the stricture. Results The length of buccal mucosa ranged from 3.5 to 17 cm (average length 6.2). In 8 patients, other reconstructive techniques were used concomitantly, including fasciocutaneous penile flap or stricture excision and primary anastomosis, depending on the length and severity of the scarred area. Median follow-up time was 18 months. Excellent results were obtained in all 13 patients and none has required urethral dilation or instrumentation subsequently. Operative time was significantly less than with other forms of substitution urethroplasty. Conclusions Excellent results can be expected when buccal mucosa is used for urethral substitution in men with refractory bulbar strictures. For patients with long or dense strictures, buccal mucosal grafts may easily be combined with other reconstructive techniques. In patients with less complex stricture disease, the reduced operative time of this two-team approach may be beneficial.

Reconstruction of Extensive Urethral Strictures: Circular Fasciocutaneous Penile Flap

The circular fasciocutaneous penile flap originates on the distal penis and uses Buck’s fascia as the major vascular conduit. It is hairless, provides up to 15cm. of length, adapts to the entire anterior urethra, can be used in circumcised men, and provides the opportunity for 1-stage reconstruction of complex anterior strictures with excellent functional and cosmetic results. The flap was used in 10 patients with complex strictures 8 to 21cm. long: 1 substitution urethroplasty of 8cm. and 9 onlay urethroplasties (2 of which used a free penile skin graft and a bladder mucosa graft as supplementation to bridge defects of 18 and 21cm., respectively). All patients have normal erectile function. No dilations were required, no strictures have recurred (mean followup 14.4 months) and mean maximal urinary flow rates are normal (mean 21.7ml. per second, range 18 to 30).

One-Stage Urethroplasty for Complicated Urethral Strictures using Axial Penile Skin Island Flap

Surgical repair of urethral strictures complicated by multiple scrotal/perineal urethrocutaneous fistulae (watering-can perineum) can be very problematic. The perineal/scrotal skin is either not available or is riddled with infection, fibrosis or granulomata and therefore unsuitable as a graft source. The presence of infection makes free grafts from other sites unlikely to survive. Furthermore, extensive fibrosis may prevent excision and re-anastomosis as well as internal urethrotomy. The absence of preputial skin in circumcised patients compounds these problems. We have used a one-stage, transverse vascularized cutaneous penile flap to repair 20 cases of these complicated strictures. The graft took in 100% and no absolute repair failure was registered. In spite of obvious pre-operative infection, the result of repair was judged excellent in 17 patients (85%) and very fair in 3 (15%).