Urétroplastie pour sténose de l’urètre bulbaire

Urethroplasty for bulbar urethral stenosis with free flap oral mucosa

Most strictures of the currently observed male urethra are located at the bulbar urethra. The free flap urethroplasty oral mucosa, according to BARBAGLI technique is the treatment we realize preferentially in this indication in case of failure of endoscopic urétrotomies.

Description ventral urethroplasty with oral mucosa free flap

The narrowing of the urethra being defined as a reduction in the caliber of the urethral canal, urethroplasty restores normal urethral caliber sustainable way.

The procedure is performed under general anesthesia. The anesthetist puts his endotracheal tube through the nose to give free oral cavity which will be performed for Reconstruction removal of the lining to the inside of the cheek.

The patient is placed in position on the size (quite close to the lithotomy position) and two drapes are prepared: the perineum and the oral cavity.

 

uretroplastie ventrale

 

The first time the procedure is cystoscopy, which allows the surgeon to intubated

r stenosis with a metal marker guide wire that is pushed to the bladder, so as not to lose the path of the stenosis.

Then the surgeon incised vertically perineum between scholarships and anus and after crossing different planes, it addresses the bulbous urethra. It is not necessary to free the urethra on all sides and make the turn completely but simply to clear his ventral and lateral surfaces, which spares the vasculature.

The removal of the oral mucosa flap is then performed by the same surgeon, unless a second double of organization surgeon has already made this levy as two separate drapes were prepared, allowing a substantial saving of time . A flap around 5 centimeters long and 2 centimeters wide and fat is removed.

 

Prélèvement du lambeau de muqueuse

 

 

We must expect a higher retraction of the graft on the order of 30%. The main landmark is the parotid duct, which drains the parotid gland. The design of the graft prior to its removal remains at least one centimeter of the opening of this channel to be sure not to hurt him. The wound of the engraftment, to the internal face of the cheek, is then closed with interrupted sutures of fast resorption thread.

The urethra is then opened in safe zone at the distal limit of the stenosis and the light of the stenotic urethra, indicated by the guide wire is flattened by near-sectional close until it reaches the proximal portion healthy.

 

Ouverture uretre


This flattening face the loss of urethral substance that is fulfilled and increased by the oral mucosal flap to the banks of which it is sutured with absorbable thread.

 

Suturation du tissu spongieux

The spongy tissue of the bulb of the urethra is sutured by covering the free graft in separate points of reasury probable-wire, and a urinary catheter is placed in the urethra, intubating the urethroplasty.

The superficial layers are then restored and skin closed with rapidly absorbable wire, usually without drainage.

We also have a habit of infiltrating the pudendal nerve with an anesthetic solution for analgesia for postoperative suites.

 

Possible operating conditions

The buccal mucosa graft can be placed:

  • ventral as we have described it;
  • dorsal, requiring dissection of the largest urethra.

 

Placement greffon de muqueuse buccale

 

 

Preoperative Evaluation

It is detailed in our page dedicated to the diagnosis of urethral stricture.

The urologist must specify before operating characteristics of stenosis: seat length, tight or not the shrinkage, impact of the stenosis, complications that could lead

Among the useful explorations in this evaluation:

– The urethrovesical endoscopy which allows the diagnosis of stenosis and accurate sound possible tight character and its headquarters;

– Radiological opacification of the urethra, usually by a urethro VCUG and retrograde mictionelle;

– A cytobacteriological urinalysis and a blood balance sheet look a urinary tract infection or kidney failure;

– A pre-anesthetic consultation.

Adjustments to the patient’s personal treatment are eventually made, particularly if treated with anticoagulants or anti-platelet aggrégants.

Operation Suites

They are usually not painful.

The patient is lifted the day after surgery.

Post-operative care includes:

  • liquid diet in the early days and mouthwashes. Ice pack on the cheek.
  • a broad-spectrum antibiotics for 3 days
  • dry dressing on the perineum.
  • Expected release in the fourth postoperative day with the urinary catheter paired on a leg bag, free flow. It should not be clamped (closed) during the period it remains in place. It is desirable that the patient takes a urinary antiseptic treatment during the time he is probed
  • The patient will practice massage oral scar to soften.

The bladder catheter was removed on day 21 after the operation under cover of a opacification by the radiologist to control the absence of fistula.

In the days following the withdrawal, sometimes the patient feels burns during urination and / or traces of blood were found in his urine.

No other biological exploration or imaging is needed after surgery during hospitalization.

The son of the perineal skin usually go away in the month following the intervention.

Postoperative consultation in the following quarter the intervention, notably enables the surgeon:

– Assess the improved strength of the urinary stream by a flow measurements, and measuring residual urine by échoscopie;

– To verify the absence of infection with a cyto-bacteriological analysis

Thereafter it is recommended to avoid applying excessive pressure on the scrotum or perineum, and in particular to avoid horse riding, cycling or playing sports of contact or combat.

 

Risks and complications associated with surgery

Apart from complications related to patient ground (including its comorbidities) or anesthesia, those directly related to the operation are rare and occur in less than 10% of operated patients.

Heavy smoking compromises the quality of healing and exposed to a higher rate of complications.

Post-operative complications are mainly represented by:

  • post-operative bleeding and bruising including the establishment of a secondary infection may secondarily and that sometimes evacuated under cover of a new anesthesia;
  • urethral fistula communication between the urethra and the reconstructed skin of the scrotum or perineum. If the fistula does not close spontaneously under a urinary drainage, a new urethroplasty is required after a period of 6 months following the first intervention for closure;
  • Infection announced by redness, heat and painful fluctuation tissue, pus after the scar and fever. The risk is the formation of an abscess it will evacuate and undermines the success of the repair.

In the longer term, support default urethral floor is rarely the cause of the formation of bags under urethral at the urethroplasty.

A slow urinary stream or drip is a common consequence (about 20%) of the intervention.

 

Advantages and disadvantages of the method

The bulbar urethroplasty with oral mucosa flap is usually very well tolerated and little invasively procedure. The operative risk is limited. The hospital stay is relatively short.

It takes a month of interruption of personal and professional activities. Recurrences are possible but rare.

 

Patient resting period

The procedure usually takes two to four hours depending on the difficulties encountered. It is a technically demanding procedure.

The hospitalization lasts 4 days and in our practice the patient leaves with the urinary catheter paired on one leg pocket.

The recovery of all the personal and professional activities is possible after a month of convalescence subject to horse riding, cycling and contact sports.

The resumption of sexual activity is also fast, after a period of the same order. The intervention has no risk of sequelae type of erectile impotence and sexual life is usually improved after the treatment of urethral stenosis.

 

Success rate

The success rate of urethroplasty with oral mucosa flap are high BARBAGLI in 2008 published a success rate of 82.8% for a time urethroplasty using a buccal mucosa flap.

 

Recurrences

In 2008, BARBAGLI and collaborators published a retrospective analysis of results obtained in 375 patients treated with bulbar urethroplasty in a time performed in several different techniques, after a mean postoperative period of 53 months. Among these 170 patients were operated by Urethroplasty using a patch either of preputial mucous or buccal mucosa. The latter allows a success rate of 82.8% much higher than the success rate obtained with the prenuptial mucosa (59.6%), while the failure rate is 17.2%.

Iterative stenoses are usually located at one or both ends of the patch. She sometimes for the entire urethroplasty. They are amenable to treatment by endoscopic urethrotomy or new urethroplasty in one or two stages.

Conclusion

The first ventral urethroplasty of the bulb of the urethra is simple, quick, minimally invasive and allows the surgeon during the intervention adapted to the surgical technique encountered lesions and intraoperative findings

Direct access to the light of the urethra helps maintain maximum continuity of urethral tissue and achieve a tight suture of the oral mucosa flap in the urethral mucosa.

It requires a less extensive dissection and preserves the blood supply and innervation of the urethra greatly reducing the risk of subsequent erectile dysfunction.

Some bibliographical elements

1) Barbagli G, Guazzoni G, Lazzeri M.

One-stage bulbar urethroplasty: retrospective analysis of the results in 375 patients.

Eur Urol 2008; 53: 828.

 

2) Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M.

Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: are results affected by the surgical technique?

J Urol. 2005 Sep;174(3):955-7; discussion 957-8.

 

3) Enzo Palminteria,  Elisa Berdondinia, Giovanni Battista Di Pierrob

The advantages of the ventral approach to bulbar urethroplasty

Arab Journal of Urology

Volume 11, Issue 4, December 2013, Pages 350–354

 

4) Guido Barbaglia, Francesco Montorsib, Giorgio Guazzonib, Alessandro Larcherb, Nicola Fossatib, Salvatore Sansalonea, Giuseppe Romanoa, Nicolòmaria Buffib and Massimo Lazzerib lowast

Ventral Oral Mucosal Onlay Graft Urethroplasty in Nontraumatic Bulbar Urethral Strictures: Surgical Technique and Multivariable Analysis of Results in 214 Patients

European Urology, Volume 64 Issue 3, September 2013, Pages 440-447

 

5) Mahmoud Mustafa, Dina Abugaber, Sacit Nurigorgel, Ertugrul Sefik, Ozan Horsanali and Wael Sadaqah (2011).

Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques, Current Concepts of

Urethroplasty,

Dr Ivo Donkov (Ed.), ISBN: 978-953-307-392-7, InTech, Available from:

http://www.intechopen.com/books/current-concepts-of-urethroplasty/urethroplasty-wide-range-of-therapeuticindications-and-surgical-techniques