ABSTRACT
Open urethral reconstruction is the procedure of choice for urethral strictures associated with dense spongiofibrosis or other factors suggesting that direct vision internal urethrotomy (DVIU) will not be effective. These may include stricture length of more than 1 cm, penile or penoscrotal location, presence of multiple strictures,6 and greater than 75% narrowing of the strictured urethral lumen as measured on RUG.7
Urethral reconstruction is also indicated when more conservative forms of treatment such as internal urethrotomy or dilatation have failed. It is important to allow the urethra to be free of instrumentation for approximately 3 months prior to urethral reconstruction in order to allow the stricture to fully declare itself and be ‘at its worst’ at the time of repair so it is not underestimated. If a patient cannot make it for 3 months without obstructing, a suprapubic catheter is placed. There are a variety of surgical techniques available to the reconstructive surgeon depending on stricture length, location, and density. Excision with primary urethral anastomosis (EPA) is the optimal method of urethral reconstruction when feasible. Its use, however, is generally limited to strictures within the bulbous urethra that are 2.5-3 cm in length due to constraints on urethral mobilization and extensibility. Strictures that cannot be reconstructed by EPA require substitution urethroplasty. In this technique, a urethrotomy incision is made through the stricture and into healthy urethra proximally and distally. Tissue in the form of a graft or a flap is then transferred into the resulting urethral defect in order to reestablish urethral continuity. As noted previously, BM has emerged as the most commonly used and effective material for substitution urethroplasty. BM has a thick, non-keratinized epithelium that makes it easy to handle and suture. The thin, richly vascularized lamina propria leads to excellent graft take and the donor site morbidity is very acceptable. In addition, it is a ‘moist’ epithelium and this may also have favorable implications for long-term success.
