Monday, March 22, 2010

Long segment urethral stricture caused by Balanitis Xerotica Obliterans treated in single stage

A 57 –year old gentleman came WITH PAN URETHRAL STRICTURE. He underwent multiple endoscopic interventions and dilatations over a period of 5 years.He had history of recurrent UTIs because of stricture.
The Ascending urethrogram revealed long segment anterior urethral stricture with meatal involvement. Clinically he had Balanitis Xerotica Obliterans and indurated urethra in the penile region.







He was taken up for endo-assessment which revealed stricture involving meatus and extending into the penile urethra till the mid-bulbar region with diverticuli in bulbar region.
The Pan-urethral stricture is a challenging situation for a urologist. Furethermore, the BXO causing pan-urethral stricture is even more complex because it has wide spread involvement in the penile skin/prepuce urethra and also proximal urethral involvement as in our case where he had bulbar stricture also
Clinically in Lichen sclerosis there are hypo-pigmented patches on the glans and the prepuce, obliteration of the coronal sulcus, deformed glans and meatal stenosis.
Various tissues have been used for the repair of long urethral strictures either in form of free grafts or pedicled flaps. The tissues used for substitution are skin either genital or extra genital, or mucosa from the oral cavity. The methods for substitution have been in form of free grafts, pedicled flaps, and tubularised flaps and graft, which are, used either in a single stage or two stage surgical reconstructions.

Johanson described the most common 2-stage repairs. The majority of failures of the Johanson technique were secondary to hair growth in the urethra, which caused infection and stone formation. This led to recurrence of the stricture. Strictures complicated by a lack of sufficient penile skin has generally consisted of 2-stage scrotal inlay urethroplasty. Scrotal skin has shortcomings, most notably hair formation, diverticula and stricture recurrence from urine-induced dermatitis.
We did single stage urethroplasty – with Kulkarni´s single stage penile invagination technique and dorsal onlay with Buccal Mucosal Graft.
The procedure was done as follows: A midline perineal incision was given and the left sided dissection of the bulbar urethra was done. One sided dissection helps to maintain the blood supply of the urethra coming from the right side. The penis in invaginated through the perineal wound and the process of the dissection is carried out further. After the full dissection the urethra is opened dorso-laterally along the whole length of the urethra (till mid-bulbar region)
The meatus is then cut dorsally widely and the BMG harvested ( we had to harvest two Buccal mucosal grafts from each side of the mouth)








was sutured to the cut edges of the meatotomy.






Then the BMG was pushed through the meatus in the urethra which is invaginated in the perineal wound. The BMG was quilted through-out the length to the underlying corpora and sutured to the cut edge of the opened urethra.







The neo-urethra combined with the BMG now quilted and the original narrowed urethra was confirmed to be adequate on the scale.






Then a 16 Fr SILICON catheter was kept in situ and the two edges of the urethra were sutured so the neo-urethra is completely re-tubularised in the entire length. The perineal wound was then closed in layers.
The plan is now to keep catheter for 4 weeks followed by Micturating cystourethrography.

3 comments:

  1. Thank you for sharing your experience. So, what was the outcome? I hope the patient did well. My own approach to pan-urethral stricture disease secondary to lichen sclerosus (Balanitis Xerotica Obliterans) at the Center for Reconstructive Urology is to do a one stage repair of the bulbar urethra using bilateral buccal grafts, and then do a 2 stage repair distally using split thickness skin grafts (STSG). During the 2nd stage, I do not make a major effort to bring the opening too far distally along the glans given the high risk of recurrence others have reported. This is quite a difficult and challenging problem.

    Joel Gelman, M.D.
    Department of Urology
    UC, Irvine Medical Center

    http://www.centerforreconstructiveurology.org/urethralstricture/lichensclerosis.htm

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  2. Thanks for sharing the information about the Long segment urethral stricture caused by Balanitis Xerotica Obliterans treated in single stage.
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