Review – Reconstructive UrologyWhat is the Best Technique for Urethroplasty?
Introduction
Urethral strictures have always been common. Urethral dilators dating to 3000 BC have been found in the tombs of pharaohs to allow them to dilate their strictures in the afterlife. Internal urethrotomy does not have a history spanning 5 millennia—only 2 millennia! The ancients knew that having a stricture meant having it for life, even if treatment was only occasional, but only recently has this idea been given an evidence base [1], [2], [3]. For patients in whom dilatation and urethrotomy proved impossible, there were only three alternatives. The first, natural, solution was to hope for the development of a urinary fistula so that at least the urine could escape somehow. The other two options were dangerous: either external urethrotomy, cutting down into the perineum blindly until the urethra proximal to the obstruction was found, or alternatively a cystostomy, either suprapubic or transrectal. That was all that was available until the pioneering developments in urethroplasty, mainly in the 1950s and 1960s. Since then, there have been essentially two principal surgical approaches available: anastomotic urethroplasty for a short stricture and substitution urethroplasty for a long stricture. Anastomotic urethroplasty became successful when techniques were developed to relieve tension at the anastomosis [4]. Substitution urethroplasty originally used skin grafts or flaps to restore urethral calibre and was technically demanding [4], [5], [6], [7], but the introduction of buccal mucosal grafting [8] and its widespread application in the last 15 yr has made substitution urethroplasty quicker and easier for both surgeons and patients.
The other (and more important) recent change is the change in the patient population presenting for urethroplasty. Twenty years ago urethroplasty was only considered after instrumentation had become impossible or produced bleeding and septicaemia or had been used for many years. Patients commonly presented in retention with a suprapubic catheter, and they were usually older and less fit than today's patients. As anaesthetic care, antibiotic treatment, and other medical improvements have made the procedure safer and as patients are presenting earlier with their problems, so urethroplasty has become easier and more popular—so easy and popular, in fact, that recent assessment of the cost-effectiveness of urethroplasty compared with dilatation and urethrotomy suggests that there is no advantage to doing more than one urethrotomy before proceeding to urethroplasty [9], [10]. Indeed, some would suggest that if a patient has a significant stricture, then a primary urethroplasty is the best treatment [9]. Nonetheless, many, if not most, urologists believe that there is a “reconstructive ladder” and that treatment should always start at the bottom with dilatation and urethrotomy and work up the ladder to urethroplasty as a last resort [11]. This is nonsense. Unless a patient has a single, previously untreated, short, membrane-like stricture of the bulbar urethra, in which case there is a 50% chance of a cure with dilatation or urethrotomy, the only predictable cure for a urethral stricture at present is a urethroplasty.
This review addresses the types of stricture problems and their frequencies; as well as the options for urethroplasty at different sites and for different types of stricture, indicating which procedure should be used in which circumstances according to the best available evidence.
Section snippets
Incidence, anatomy, and aetiology
Urethral strictures are uncommon in children and become increasingly common in a linear fashion until the age of about 55 yr. Thereafter the incidence increases sharply [12], [13], probably as peripheral vascular disease causes urethral ischaemia. Strictures are rare in women but not unknown [14]. Symptomatic strictures requiring treatment are the best indicators we have of exactly how common they are, and these are most easily identified by hospital admission data such as the Hospital Episode
Bulbar urethroplasty
The gold standard for the first-time treatment of a short, sharp stricture of the bulbar urethra is excision, spatulation of the two ends, and an overlapping end-to-end anastomosis, whether or not the lumen is completely occluded [27], [28]. Equally the gold standard for a stricture of the bulbar urethra of ≥2 cm in length, where the urethral lumen is relatively well preserved and the spongiofibrosis around the lumen is limited to a millimetre or two circumferentially, is a stricturotomy and
Obliterative strictures
The literature makes little or no distinction between a urethroplasty for a stricture in which the lumen is more or less completely obliterated and one in which the lumen is significantly narrowed but not actually lost. As a result, evidence gives way to opinion, and there is no gold standard for the treatment of long bulbar (or penile) strictures that are more or less obliterative with spongiofibrosis to a much greater degree than just a couple of millimetres around the lumen. Standard patch
Other difficult strictures
If there is failure of a previous BMG (or other graft) in a young patient with a good blood supply to the urethra, excision of the stricture and redoing the graft may be feasible. Either the remnants of a dorsal patch are removed and a new dorsal patch is placed, or alternatively a ventral graft or flap is placed. Revisional surgery is often technically difficult but may be more than just technically difficult when the stricture reaches up to or involves the sphincter mechanism. In such cases
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