MYERS and MCANINCH
MYERS and MCANINCH
BJUI
Surgery Illustrated Surgical Atlas
Perineal urethrostomy
BJU INTERNATIONAL
Jeremy B. Myers and Jack W. McAninch
Department of Urology, The University of California San Francisco, San Francisco, California, USA
ILLUSTRATIONS by STEPHAN SPITZER, [Link]
KEYWORDS
perineal urethrostomy, lichen sclerosis,
urethra, stricture, reconstruction
INTRODUCTION
The surgical options for the treatment of
anterior urethral strictures are extremely
diverse. They include endoscopic procedures
as well as a multitude of urethroplasty
techniques [13]. The success rate of
urethroplasty is excellent and for most
techniques it is 80% [4]. Despite this
excellent success rate, there are several
conditions that make urethral reconstruction
challenging and may decrease its ultimate
success. One example is lengthy strictures
involving the entire anterior urethra. These
panurethral strictures can arise from various
causes, but are notorious in the setting of
lichen sclerosis. Other conditions, which
decrease the success of anterior urethral
reconstruction, are patients with multiple
failed urethroplasties [5], history of
hypospadias repair [6], and prior pelvic
radiation therapy [7].
An alternative to urethroplasty in patients
with unfavourable urethral pathology is
perineal urethrostomy. A perineal
urethrostomy is placed proximally in the
bulbar urethra, just distal to the external
sphincter allowing for diversion of urine
proximal to the majority of the anterior
urethra [8]. In addition to men with
unfavourable urethral pathology, perineal
urethrostomy is also a good option for men
who do not desire extensive urethral
reconstruction. Many of these men are older
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and often they are not concerned with
needing to sit to void after surgery.
combined with a history of prostate resection
or ablative procedures is a relative
contraindication.
PLANNING AND PREPARATION
RECOMMENDED EQUIPMENT
INDICATIONS AND PATIENT SELECTION
Perineal retractor (e.g. perineal Bookwalter,
Lone Star retractor).
Sacral bump.
Atraumatic forceps.
Bipolar cautery.
Fine serrated dissecting scissors.
compression devices are used during the
operation.
POSITIONING
Patients who choose to undergo perineal
urethrostomy either have unfavourable
urethral pathology for reconstruction or do
not desire extensive surgery. Patients with
contraindications to perineal urethrostomy
are those with extensive disease proximal to
the bulbomembranous junction such as
prostatic urethral stenosis or bladder neck
contracture. In addition, placement of an
artificial urinary sphincter is not a good
option after perineal urethrostomy and poor
external sphincteric function especially
PATIENT PREPARATION
A preoperative urine culture is done to assure
sterile urine in patients undergoing perineal
urethrostomy. Patients are given immediate
preoperative broad-spectrum antibiotics
before making an incision. Sequential
After undergoing general endotracheal
anaesthesia, patients are placed into a high
lithotomy position using candy cane stirrups.
A sacral bump (we use a bean bag covered by
a gel pad) is used to support and rotate the
pelvis so the perineum and proximal urethra
are easily accessible to the surgeon. Care is
taken to make sure all pressure points are
adequately padded. Complications in this
position are rare [9], and should not occur if
the duration of the operation is <5 h [10]. In
addition to establishing an optimal position
for access to the proximal urethra, the high
lithotomy position allows two standing
surgeons to operate side by side with ease.
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Figure 1
After patients are positioned into the high
lithotomy position (a) an inverted U-shape
incision is made (b). The apex of the inverted
U is located in the upper portion of the
perineum just below the scrotum; this
incision acts to relax the perineum and
facilitates a tension-free anastomosis
between the skin and urethra. This relaxing
incision is especially important when patients
are obese or have had previous perineal
surgery.
In some cases, a midline incision extending
cephalad from the apex of the inverted U is
made if the opening in the skin of the
perineum is not large enough for the
corresponding urethrotomy.
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Figure 2
An important component to the inverted U
incision and flap is the mobilization of a full
thickness fat pad underneath it, directly off of
the underlying bulbocavernosus muscle. This
manoeuvre helps assure a good vascular
supply to the apex of the flap.
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Figure 3
Once the inverted U flap is developed, the
bulbocavernosus muscle is separated,
exposing the bulbar urethra.
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Figure 4
The urethra is then grasped with two pairs of
forceps above and below the area of planned
incision. A knife is then used to make a
longitudinal incision ventrally into the urethra
measuring 4 cm.
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Figure 5
Stay sutures are placed and the urethra is
calibrated with a bougie towards the bladder
to make sure there is no stricture proximal to
the urethrotomy. If strictured urethra is
identified proximally, then the ventral urethral
incision is extended towards the membranous
urethra until an uninvolved area is found.
Cystourethroscopy is performed to evaluate
the distance to the external sphincter as well
as to identify potential issues such as
obstructive prostatic disease or bladder
calculi.
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Figure 6
The skin of the perineum is then sutured to
the open urethrotomy preserving the dorsal
urethral plate. This starts with bringing the
apex of the inverted U incision to the
proximal margin of the urethrotomy. During
placement of sutures, care is taken to
incorporate three important layers: the
urethral mucosal edge, the adventitial edge of
the corpus spongiosum, and lastly the skin
edge. This method preserves blood supply
within the corpus spongiosum, in contrast to
the effect of a full thickness suture through
the corpus spongiosum. To help reduce any
tension on the inverted U flap, we also place
several sutures in the subdermal tissue of the
body of the flap, securing these sutures to
dense tissue surrounding the bulbar urethra.
Interrupted absorbable suture, consisting of
2-0 or 3-0 polyglactin (Vicryl, Ethicon Inc.), is
used to mature the perineal urethrostomy.
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Figure 7
Once the skin is brought down to the urethra
around the entire urethrotomy, two openings
exist between the urethra and the skin. The
proximal opening of the urethra leads
towards the bladder and the distal urethral
opening leads out towards the penis. The
dorsal urethral plate remains intact, as well as
the longitudinal blood flow within the corpus
spongiosum. A Foley catheter is placed
through the proximal portion of the
urethrotomy into the bladder and patients are
admitted to the surgical ward for recovery.
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POSTOPERATIVE CARE
Patients during the postoperative period are
treated with antibiotics until the catheter is
removed. Usually the catheter is left in situ for
47 days. If there is any concern about local
tissue healing at the inverted U advancement
flap, then the catheter can be left for a longer
period. Patients are followed at regular
intervals in our clinic. Cystourethroscopy is
performed at 3 and 12 months or if there is
any concern of stenosis, based upon
symptoms, UTI, a low urinary flow rate, or an
increase in postvoid residual urine volume.
After 1 year, patients are followed by
symptoms, urinary flow rate and
measurement of residual urine every
612 months.
SURGEON TO SURGEON
Patients who have anterior urethral stricture
disease and have not had previous perineal
surgery are ideal candidates for perineal
urethrostomy. In most of these cases the
proximal bulbar urethra is free of disease and
has relative normal anatomy. The types of
cases that might present in this manner are
patients with lichen sclerosis involving the
distal urethra, squamous cell carcinoma of
the penis, or older men with stricture disease
who do not want reconstruction but prefer
the concept of perineal urethrostomy.
Patients who represent more difficult cases
are those with previous perineal surgery such
as resection for Fourniers gangrene, previous
failed perineal surgery for stricture disease,
and morbidly obese men. In addition, caution
must be advised in men with previous
radiation for prostate cancer as we have
found these men to be much more prone to
postoperative stenosis of the perineal
urethrostomy.
One technical aspect of the operation that can
help is the high lithotomy position. This
position allows the best access to the
proximal urethra and allows creation of the
perineal urethrostomy up to the level of the
external sphincter if necessary. An additional
surgical pearl is to make sure the inverted U
flap extends up close to the junction of the
scrotum. Once this inverted U flap is released
off of the bulbocavernosus muscle it
contracts substantially. Especially in men with
previous surgery or who are obese, the length
of this flap is crucial to create a tension-free
anastomosis between the apex of the flap and
the proximal urethrotomy.
The most common intraoperative problem is
stricture that extends from the area of the
bulbar urethra towards the external sphincter.
Usually this problem can be dealt with by
extending the ventral urethrotomy up to the
level of the external sphincter. On occasion
the dorsal plate of the urethra is very diseased
and not suitable for creation of the perineal
urethrostomy. In these circumstances, it is
worthwhile adding a dorsal buccal mucosal
graft to recreate a dorsal plate for the length
of the perineal urethrostomy, so that the area
does not contract with wound healing and
time.
CONCLUSIONS
Perineal urethrostomy represents a good
alternative to urethral reconstruction in men
with anterior urethral disease arising from
various problems. The success rate, even when
stricture disease is caused by conditions such
as radiation therapy, lichen sclerosis, or failed
urethroplasty, is excellent. We think that
preservation of the dorsal plate and the
longitudinal blood supple in the corpus
spongiosum are critical factors in successful
surgery.
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Correspondence: Jeremy B. Myers, University
of Utah School of Medicine, Division of
Urology, 30 North 1900 East, Room 3B420,
Salt Lake City, UT 84132, USA.
e-mail: jeremybmyers@[Link]
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