Vessel-sparing Excision and Primary Anastomosis

This vessel-sparing technique aims to reduce surgical trauma during urethroplasty by excision and primary anastomosis. Preserving the bulbar arteries could reduce the risk of post-operative erectile dysfunction and glans ischemia. Furthermore, it can be beneficial for further urethral interventions requiring a well-sustained avascularization.

After confirming the presence of a stricture by retrograde and/or antegrade urethrography, adjust the patient on the operating table in the supine position, in a modified lithotomy position with the knees and hips flexed 60 to 90 degrees, with 45 degrees of abduction, and the calves supported in leg holders. Disinfect the exposed perineum and external genitals with an iodine-based antiseptic scrub, and place sterile drapes around the operating field, including the penis and scrotum, without the anus. To access the bulbar urethra, use a number 24 scalpel blade to make a midline paraniel skin incision, and dissect the sub-cutaneous fat tissue through Colles Fascia with a monopolar electrocautery, until the bulbospongiosus muscle is encountered, cauterizing any bleeding vessels as necessary.

Incise the bulbospongiosus muscle at the midline, and use Jones scissors to dissect the muscle away from the underlying corpus spongiosum. Then, fix the bulbospongiosus muscle at the perineal skin with four silk 2-0 stay sutures. Apply a self-retaining retractor, and attach elastic stay hooks to the bulbospongiosus muscle with sufficient traction, securing the elastics to one of the slots of the retractor.

Next, dissect the bulbar urethra in a circumferential manner, starting at the mid bulbar region, to allow further dorsal dissection of the urethra and a detachment of the dorsal ducts fascia from the tunica albuginea of the corpora cavernosa. Encircle the exposed bulbar urethra with a vessel loop, and secure the loop with a kocher clamp to facilitate manipulation. Continue the dorsal dissection and detachment in the distal direction toward the penoscrotal angle using sharp scissors, and closely following the avascular surgical plane of Buck's fascia.

Then continue the dorsal dissection proximally toward the urogenital diaphram, without dissecting the bulb of the corpus spongiosum at the anal side, and leaving the bulbar arteries in tact. To open the stricture, introduce a 20 French silicone urethral catheter, or a 20 French metal sound into the meatus urethri, and pass it up toward the distal extent of the urethral stricture. At this level, use a number 24 scalpel blade to open the urethra dorsali in a longitudinal manner, and place one silk 3-0 stay suture on each side of the opened urethra, to facilitate exposure of the urethral lumen.

Insert a three French urethral catheter through the urethra and proximally up through the scrictured area, opening the stricture along the catheter until health urethral tissue is encountered. Introduce a 20 French metal sound up toward the bladder to evaluate the patency and caliber of the proximal urethra, and place one silk 3-0 stay suture on each side of the opened proximal urethra. Then resect the stricture, as well as the surrounding spongiofibrosis, until healthy spongeous is encountered ventrally, and grasp the urethral mucosa with a debakey forceps with a large grip.

It is very important to fully resect the urethral stricture and the surrounding spongiofibrosis in order to obtain two well-vascularized urethral ends. Using interrupted 4-0 sutures, licate the ventral ends of the proximal and distal urethra from the inside of the urethral lumen for creation of the ventral urethra plate. Dorsally spatulate the healthy urethral edges for about one centimeter, and remove the stay sutures.

Then use interrupted 4-0 sutures to close the dorsal edges of the urethral ends transversely, and to close the corpus spongiosum over the urethra. To prevent urethroplasty failure, it is of utmost importance to complete the anastomosis without any tension. Remove the retractor, and cut the stay sutures with mayo still scissors.

Then, perforate the skin of the right inguinal region with the 10 French drain needle. Leaving the silicone catheter in place, place a 10 French suction drain between the corpus spongiosum and the bulbospongiosus muscle. Use a 3-0 running suture to close the bulbospongiosus muscle over the underlying urethra and corpus spongiosum.

Then, suture Colles fascia in a running manner, and suture the skin with interrupted Donati stitches, both using 3-0 sutures. Use a silk 2-0 suture to fix the suction drain at the groin. Then, apply a pararenal compressive dressing.

Between 2011 and 2017, a total of 117 patients with isolated short bulbar or posterior urethral strictures were treated with vessel-sparing excision and primary anastomosis at Ghent University Hospital, with a median followup time of 35 and 45 months for bulbar and posterior strictures, respectively. The complication rate was equally low in both groups, and mainly consisted of low-grade events, such as wound dehiscence, wound infection, urinary infection, bladder spasms, and hematoma. Overall, the estimated failure-free survival was 95.3%95.3%and 87%at one, two, and five years, respectively, for the bulbar vessel-sparing excision and primary anastomosis group, and 88.3%over the same monitoring periods for the posterior vessel-sparing excision and primary anastomosis group.

To conclude, vessel-sparing excision and primary anastomosis provides excellent success rates with low complication rates for isolated, short bulbar and posterior urethral strictures.