Raj Kumar Mathur M.B.B.S., M.S. (Gen Surg), F.I.C.S., Department of Surgery, MYH Hospital and MGM Medical College, Indore, Madhya Pradesh-452001, India. Email: firstname.lastname@example.org
Objective: Over previous years, urethral stricture has constantly created a great problem in efforts to find a permanent cure for it. We describe a technique of anterior urethroplasty using tunica albuginea of corpora cavernosa.
Methods: After a midline penoscrotal incision, the bulbar or penile urethra along with corpus spongiosum was dissected from the corpora cavernosa. Urethra was then rotated dorsally and the stricture was opened along its whole length. The walls of the slit urethra, along with the tunica albuginea of the corpus spongiosum, were sutured to the tunica albuginea of the corpora cavernosa at the 5 and 7 o'clock position after passing an all silicon catheter. We performed this technique on 79 male patients, having anterior urethral stricture, ranging 18–60 years of age (mean, 46 years). The etiology of stricture was trauma in 54, instrumentation in 12, infection in 10 and unknown in three. Follow ups were done at 4, 12 and 24 months by assessing patients' satisfaction rate along with a pre- and postoperative urethrogram, labeled as ‘good’, ‘fair’ and ‘poor’.
Results: Good and fair results were considered as successful. The overall success rate was 94.9%. The success rate remained same at 4 months (64 + 11) and decreased to 93.7% (63 + 11) at 12 months and 89.9% (61 + 10) at 24 months.
Conclusion: These observations show that anterior urethroplasty using tunica albuginea of corpora cavernosa have produced satisfactory results and are comparable with any other technique of urethroplasty. Thus, we strongly recommend the use of tunica albuginea of corpora cavernosa for anterior urethroplasty, which is histologically similar and anatomically located near the stricture.
A urethral stricture is the fibrotic narrowing of the urethra composed of dense collagen and fibroblasts. In other words, strictures can be defined as ‘a decrease in the caliber of the urethra due to a scar resulting from tissue injury or inflammation’.1 Usually fibrosis involves the corpus spongiosum also.2
A wide array of techniques are used in the reconstructive surgery for anterior urethral stricture diseases, and modifications are continuously being made. Stricture excision and anastomotic repair is appropriate only for short and untreated lesions of traumatic origin. End-to-end urethroplasty for bulbar urethral stricture has greater than 95% durable cure rates and low complication rates.3 Long urethral strictures, which are not amenable to endoscopic correction, require anastomotic urethroplasty.4–7 Urethroplasty of long strictures can be done either by standard two-staged procedures (marsupialization and creation of hypospadias in one stage and closing the lateral skin in midline in a second) or substitution of the strictured part by using genital skin, buccal mucosa and bladder mucosa graft, and so forth. The restricture rates while using one-stage stricturotomy and patch urethroplasty using a flap of genital skin was approximately 11% at 1 year.8 Urethroplasty, with different grafts, usually requires technical expertise and restricture rates are high. Herein, we introduce a new technique of anterior urethroplasty by using locally available tunica albuginea of corpora cavernosa. Our technique is based on the observation that in cases of necrosis of dorsal on lay buccal mucosa graft, tunica albuginea is the supporting layer and the urethral lumen is still maintained.
Material and methods
The male urethra can be divided into two different portions: (i) the posterior urethra, which includes the membranous and the prostatic regions; and (ii) the anterior urethra. The anterior urethra includes the navicularis, penile and bulbous regions, and is surrounded by the corpus spongiosum. In the bulbar urethra, the relationship between the spongiosum tissue and the mucosal membrane is quite different from the relationship in the penile region: the corpus spongiosum is thick on the ventral urethral surface and thin on the dorsal urethral surface. Furthermore, the urethral lumen is located dorsally and not centrally.
The patient was placed in the normal lithotomy position, and a midline penoscrotal incision was given (Fig. 1a). The bulbar or penile urethra, along with corpus spongiosum, was then freed and was dissected from the corpora cavernosa (Fig. 1b). The urethra was completely mobilized from the tunica albuginea of corpora cavernosa, which was then rotated and incised along its dorsal surface. The stricture was opened along its whole length (Fig. 1c).
Thus, the lumen of the strictured segment faced the ventral aspect of the tunica albuginea of corpora cavernosa. An all-silicone urethral catheter was passed through the meatus into the bladder and retained in situ. Then, the walls of the slit urethra, along with the tunica albuginea of the corpus spongiosum, were stitched to the tunica albuginea of the corpora cavernosa using interrupted vicryl 2–0 sutures at the 5 and 7 o'clock positions (as seen in the transverse section of penis; Fig. 1d). Hemostasis was secured and fascia and skin were closed in layers (Fig. 1e). In this technique, the ventral aspect of tunica albuginea of corpora cavernosa forms the roof of neourethra and the floor is formed by a strictured portion of the urethra, along with corpus spongiosum, which is cut dorsally.
After 21 days, the catheter was removed and a voiding cystourethrography was obtained. Urine culture was repeated every 4 months during the first year and yearly thereafter.
We performed this technique on 79 patients with anterior urethral stricture (lengths ranging 2.5 cm or more to strictures involving the entire anterior urethra), with an age range of 18–60 years (mean, 46 years), using tunica albuginea of corpora cavernosa, from July 1993 to June 2003.
The etiology of stricture was trauma in 54, instrumentation in 12, infection in 10 and unknown in three. A total of 57 patients (72.2%) had undergone some previous intervention including multiple urethrotomies, dilations or some form of urethroplasty.
Detailed preoperative assessment along with careful history and physical examination was carried out. Voiding cystourethrogram and retrograde cystourethrogram were done, both pre- and postoperatively, to aid the precise site and length of stricture, and then anterior urethroplasty using tunica albuginea of corpora cavernosa was performed. After decatheterization, patients were assessed by postoperative urethrogram, and patient satisfaction based on relief of symptoms, and results were labeled as ‘good’, ‘fair’ and ‘poor’ (Table 1).
Table 1. Postoperative result assessment criteria
Anterior urethra of good caliber
Anterior urethra at some places shows narrowing
Strictured urethra + urethra distal to the stricture – narrowed
Passing urine in good stream and never required dilatation
Urine stream is slightly weakened and required dilatation
Passing urine in the weak stream with dribbling at some times and required redo operation.
Sixty-five out of 75 patients showed good results, 10 had fair results, and four patients had poor results. The overall success rate was 94.9% (good + fair). Any technique of urethroplasty deteriorates over time. In our series of patients the overall success rate of urethroplasty remained the same at 4 months (64 + 11) and decreased to 93.7% (63 + 11) at 12 months and 89.9% (61 + 10) at 24 months (Table 2). Our criteria of classifying results were based on patient satisfaction with postoperative relief of symptoms and their urethrogram. Those patients who were voiding well postoperatively and urethrogram showed no residual strictures were considered to have shown good results (Figs 2 and 3). This group also includes those patients who were not voiding preoperatively, but were satisfied with their postoperative status. Patients with fair results were those who showed some improvement postoperatively, and the dye-study showed narrowing at some places, but patency of urethra in the region of the repair. This group included patients who had undergone multiple urethrotomies and multiple dilatations with dense fibrosis of corpus spongiosum and also patients with pan urethral stricture. In the poor result group, the patients showed no improvement over their preoperative state and needed the operation redone. These patients had pan urethral strictures or recurrent strictures after any other method of urethroplasty.
Table 2. Comparing results in immediate post operative period at 4, 12 and 24 months
Results in immediate post operative period
Results at 4 months
Results at 12 months
Results at 24 months
Although Barbagli et al. has shown that a previously failed urethrotomy does not condition the long-term result of urethroplasty, in their study patients had smaller strictures localized to bulbar urethra.9
Surgical repair of anterior urethral stricture is based on end-to-end anastomotic repair for short lesions. Internal urethrotomy (IU) has the advantages of ease, simplicity, speed and short convalescence but is successful only for short strictures of < 2 cm in length.10 Newer techniques, using neodymium:yttrium–aluminium–garnet (Nd:YAG) laser core-through urethrotomy, have shown promising long-term results for post-traumatic urethral stricture of short length.11
Success of free graft apposition depends on neovascularization from the surrounding structures, failure of which leads to necrosis of graft and formation of urethroperineal fistula. Current techniques adopt graft (e.g. buccal mucosa, bladder mucosa) or flap apposition (e.g. pedicled skin flaps, skin island onlay flaps), but this often lacks the mechanical support of a fixed bed, which allows it to fold on itself, reducing the opportunity of neovascularization, and decreasing the caliber of the reconstructed urethra.12 Moreover, sacculation at the graft side or flap may occur, causing post-voiding dribbling and ejaculatory failure. Sequestration of semen and residual infected urine inside the pseudodiverticulum may further compromise the state of the adjacent urethra and facilitate recurrent stricture disease.12–17
Some people recommend that dorsal onlay buccal mucosa graft can overcome these complications, but in a study by Barbagli et al. showed that the placement of buccal mucosa grafts into the ventral, dorsal or lateral surface of the bulbar urethra showed the same success rates (83–85%) and the outcome was not affected by the surgical technique.18
The urethroplasty of anterior urethral stricture by using locally available similar structures like tunica albuginea in a single-stage procedure is easy to perform, more feasible and, moreover, anatomically similar tissues are used for approximation as the fibers of the tunica albuginea of the corpora cavernosa and corpus spongiosum are histologically similar in composition and fiber orientation.19 Both have a circular inner layer that supports and contains the respective cavernous and spongiosal tissues. From these inner layers radiates intercavernosal and spongiosal pillars, respectively, that act as struts to augment the septum, which provides essential support, thus facilitating healing without the dangers of excessive fibrosis which could lead to reformation of the stricture.
The advantages of doing urethroplasty by using tunica albuginea of corpora cavernosa are:
1Locally available tissue (tunica albuginea of corpora cavernosa) is used.
2Postoperative restricture rates are very low.
3The disadvantages of using hair-bearing skin are avoided.
4It can be used for fairly long strictures (including pan-urethral stricture) without formation of chordae postoperatively.
5Formation of urethroperineal fistula is not seen.
6Doesn't require much technical expertise.
7Cosmetically, the penis looks normal without any bending or curvatures.
Urethroplasty, by using anatomically far off and histologically dissimilar grafts, requires more expertise and the chances of restricture are high as well, especially in long strictures. Urethroplasty of anterior urethral stricture by using locally available similar tissue in a single-stage procedure is easy to perform and the postoperative results showed satisfactory results in 94.93% of the patients which is comparable to any other technique. Thus, we strongly recommend the use of tunica albuginea of corpora cavernosa, which is histologically similar and anatomically located near the stricture, rather than using distant and histologically dissimilar tissues such as buccal mucosa, skin and so forth, for anterior urethroplasty.
We would like to thank our head of department of surgery Dr PK Banerjee for allowing us to do this study.