Reconstructive and Paediatric Urology
ONE-SIDED ANTERIOR URETHROPLASTY
KULKARNI
et al.
BJUI
One-sided anterior urethroplasty: a new dorsal
onlay graft technique
BJU INTERNATIONAL
Sanjay Kulkarni, Guido Barbagli*, Salvatore Sansalone† and Massimo Lazzeri‡
Centre for Reconstructive Urethral Surgery, Pune, India; *Centre for Reconstructive Urethral Surgery, Arezzo,
†
Department of Urology, University Tor Vergata, Rome, and ‡Department of Urology, Santa Chiara-Firenze, GIOMI
Group, Florence, Italy
Accepted for publication 5 December 2008
Study Type – Therapy (case series)
Level of Evidence 4
OBJECTIVE
To investigate the feasibility, tolerability,
safety and efficacy of using a new surgical
technique for the repair of anterior urethral
strictures to preserve vascular supply to
the urethra and its entire muscular and
neurogenic support.
PATIENTS AND METHODS
In all, 24 patients (mean age 46 years)
underwent a new one-sided anterior dorsal
oral mucosal graft urethroplasty while
preserving the lateral vascular supply to the
urethra, the central tendon of the perineum,
the bulbospongiosum muscle and its
INTRODUCTION
In 1880, Duplay [1] described a method for
urethral construction in hypospadias that
was based on one of the basic principles in
urethral reconstruction, consisting of the
formation of an epithelialized tube from a
buried strip of skin. In 1949, Denis Browne [2]
described a similar method for reconstruction
of the urethra in hypospadias. Over time,
the Duplay’s and Denis Browne’s principle,
according to which the buried strip of intact
epithelium becomes an epithelialized tube,
has been widely used in reconstructive
urology. In 1980, Monseur [3] fully applied
Duplay’s principle and described the first
dorsal urethroplasty. In 1996, Morey and
McAninch [4] described the ventral onlay
graft technique and, in the same year,
Barbagli et al. [5] described the dorsal onlay
11 5 0
perineal innervation. The cause of stricture
was instrumentation in three cases (12%),
unknown in five (21%), infection in four
(17%), and lichen sclerosus in 12 (50%). The
stricture site was bulbar in 12 cases (50%)
and panurethral in 12 (50%). The mean
stricture length was 4.2 cm in patients with
bulbar strictures and 10 cm in patients with
panurethral strictures. Of 24 patients, 20
patients (83%) had received previous
treatments. Clinical outcome was considered
a failure when any postoperative
instrumentation was needed, including
dilatation.
using definitive perineal urethrostomy and
another failure underwent successful
internal urethrotomy.
CONCLUSIONS
The preservation of the one-sided vascular
supply to the urethra and its entire muscular
and neurogenic support should represent a
slight but significant step toward perfecting
the surgical technique of urethral
reconstruction using a minimally invasive
approach.
RESULTS
KEYWORDS
The overall mean (range) follow-up was
22 (12–55) months. Of the 24 patients, 22
(92%) had a successful outcome and two
(8%) were failures. One failure was treated
graft technique. These two new surgical
techniques, suggested mainly for repair
of bulbar urethral strictures, represent a
development of the Duplay-Denis Browne
principle [1,2], showing that a buried, ventral
or dorsal, strip of oral mucosa becomes an
epithelialized tube. It was 116 years later that
these authors confirmed and expanded on the
ingenious Duplay principle: each strip of
autologous epithelial tissue has the potential
of being used for urethral regeneration.
Recently, new surgical techniques have been
developed based on the dorsal onlay graft
urethroplasty first described by Barbagli et al.
[5]. In 2000, Kulkarni et al. [6] described a new,
full length (penile and bulbar), one-stage oral
mucosal graft urethroplasty in patients with
panurethral strictures due to lichen sclerosus.
In 2001, Asopa et al. [7] described an original
urethral surgery, vascular sparing technique,
bulbospongiosum muscle, perineal nerve,
central tendon of the perineum
dorsal inlay technique. These techniques
represent an interesting development of the
dorsal graft urethroplasty [5–7]. Recently,
Barbagli et al. [8] developed a muscle and
nerve-sparing bulbar urethroplasty, to
preserve the bulbospongiosum muscle and its
perineal innervations, thus suggesting a new
minimally invasive alternative to traditional
ventral or dorsal bulbar urethroplasty.
We combined the use of muscle- and nervesparing bulbar urethroplasty from the
technique of Barbagli et al. [8] with the fulllength dorsal urethral opening from the
technique of Kulkarni et al. [6], and described
a new surgical technique for the repair of
anterior urethral strictures, so as to preserve
the lateral vascular supply to the urethra,
the central tendon of the perineum, the
bulbospongiosum muscle and its perineal
©
JOURNAL COMPILATION
©
2009 THE AUTHORS
2 0 0 9 B J U I N T E R N A T I O N A L | 1 0 4 , 11 5 0 – 11 5 5 | doi:10.1111/j.1464-410X.2009.08590.x
ONE-SIDED ANTERIOR URETHROPLASTY
FIG. 1. The preparation of the bulbar urethra starts only on the left side, leaving the lateral blood supply to the
urethra, the bulbospongiosum muscle and the central tendon of perineum intact.
b
a
culture, residual urine measurement,
uroflowmetry, and retrograde and voiding
cystourethrography. The cause of stricture
was previous urethral instrumentation in
three cases (12%), unknown in five cases
(21%), infection in four cases (17%), and
lichen sclerosus in 12 cases (50%). The
stricture site was bulbar in 12 cases (50%) and
panurethral (involving both penile and bulbar
tracts) in 12 cases (50%). The mean (range)
stricture length was 4.2 (3.5–6) cm in patients
with single bulbar urethral involvement and
10 (8.5–14.5) cm in patients with panurethral
strictures. Of the 24 patients, 20 patients
(83%) had received previous treatments:
internal urethrotomy, six (25%); dilatation,
three (13%); urethroplasty, seven (30%);
multiple treatments, four (16%).
SURGICAL TECHNIQUE
FIG. 2. The urethra is mobilized from the albuginea only along the left side avoiding the full circumferential
dissection of the urethra from the corpora cavernosa. The longitudinal incision along the lateral urethral
surface is underlined.
b
a
innervation, and report the preliminary results
in a limited series of patients.
PATIENTS AND METHODS
From January 2004 to August 2007, 24
patients (mean age 46 years, range 32–73)
underwent a one-sided anterior dorsal oral
©
mucosal graft urethroplasty, while preserving
the lateral vascular supply to the urethra,
the central tendon of the perineum, the
bulbospongiosum muscle and its perineal
innervation.
Preoperative evaluation included clinical
history, physical examination, urine
The patient is placed in a simple lithotomy
position. The patient’s calves are carefully
placed in Allen stirrups with sequential
inflatable compression sleeves and the lower
extremities are then suspended by the
patient’s feet within the boots of the stirrups.
Proper positioning ensures that there is no
pressure on any aspect of the calf muscles
and no inward boot rotation, to avoid perineal
nerve injury. The skin of the suprapubic
region, scrotum and perineum is shaved
and this region is prepared and draped
appropriately. The oral mucosal graft is
harvested from the cheek according to the
standard technique. Methylene blue is
injected into the urethra to better define the
urethral mucosa. A midline perineal incision is
made. The bulbar urethra is dissected from
the corpora cavernosa only along the left
side, starting from the distal tract where
muscles are absent (Fig. 1), leaving the
bulbospongiosum muscle and the central
tendon of the perineum intact (Fig. 1). Along
the right side, the urethra remains attached to
the corpora cavernosa for its full length, thus
preserving its lateral vascular blood supply
(Fig. 1). On the left side, the urethra is partially
rotated and the lateral urethral surface is
underlined (Fig. 2). The distal extent of the
stenosis is identified, the dorsal urethral
surface is incised along the midline and
the urethral lumen is exposed (Fig. 3). The
stricture is then incised along its entire length
by extending the urethrotomy distally and
proximally (Fig. 3). Once the entire stricture
has been incised, the length and width of the
remaining urethral plate is measured. The oral
mucosal graft is trimmed to an appropriate
2009 THE AUTHORS
JOURNAL COMPILATION
©
2009 BJU INTERNATIONAL
11 5 1
K U L K A R N I ET AL.
size according to the length and width of the
urethrotomy, and it is spread fixed over the
tunica albuginea (Fig. 4). The two apices of the
graft are sutured to the proximal and distal
apices of the urethrotomy. The right margin of
the oral graft is sutured to the left margin of
the urethral mucosal plate (Fig. 4). A Foley
16 F grooved silicone catheter is inserted
(Fig. 5). The bulbar urethra, with the intact
bulbospongiosum muscle, is rotated to its
original position over the graft (Fig. 6).
Interrupted 4/0 polyglactin sutures are used
to stabilize the urethral margins onto the
corpora cavernosa over the graft on the left
side (Fig. 7). At the end of the procedure, the
graft is completely covered by the urethra,
then by the muscles (Fig. 7). Colles’ fascia, the
perineal fat and the skin are closed with
interrupted absorbable sutures. The catheter
is left in situ for 3 weeks.
In patients with panurethral strictures, a
midline perineal incision is made and the
bulbar urethra is dissected, only on the left
side, from the corpora cavernosa starting
from the distal tract where muscles are
absent, leaving the bulbospongiosum muscle
and the central tendon of the perineum
intact. On the right side, the urethra remains
attached to the corpora cavernosa for its full
length, thus preserving its lateral vascular
blood supply dissected from the corpora
cavernosa. By invaginating the penis into
the perineal incision, the penile urethra is
similarly dissected, only along the left side,
from the corpora cavernosa up to the coronal
sulcus (Fig. 8A). On the left side, the urethra is
partially rotated, the dorsal urethral surface is
incised along the midline and the bulbar and
penile urethra are opened along the dorsal
surface. A wide meatotomy is performed
dorsally from the meatus through the urethra
inside the glans. The first oral mucosa graft is
sutured to the dorsal edge of the meatus and
pushed inside the opened penile urethra and
fixed to the corpora cavernosa. Another
oral mucosa graft is applied to the corpora
cavernosa opposite the bulbar urethra
(Fig. 8B). Continuous upward traction is
applied to the inverted penis while applying
the penile portion of the graft to prevent
chordee. Quilting sutures are used to spread
and fix the graft to the corpora. The right side
of the oral graft is sutured to the left side of
the urethral mucosal plate. A Foley 16 F
grooved silicone catheter is inserted. The full
length of the urethra, with the intact
bulbospongiosum muscle, is rotated to its
original position over the graft. Interrupted
11 5 2
FIG. 3. The urethra is longitudinally opened along its lateral surface.
b
a
FIG. 4. The oral mucosal graft is fixed to the underlying albuginea and the right margin of the oral graft is
sutured to the left margin of the urethral plate.
b
a
4/0 polyglactin sutures are used to stabilize
the urethral margins onto the corpora
cavernosa over the graft on the left side. At
the end of the procedure, the graft is
completely covered by the urethra, then by
the muscles. Colles’ fascia, the perineal fat
and the skin are closed with interrupted
absorbable sutures. The catheter is left in situ
for 3 weeks.
The patient ambulates on the first
postoperative day and is discharged from the
hospital 3 days after surgery. All patients
receive broad-spectrum antibiotics and are
maintained on oral antibiotics until the
catheter is removed. At 3 weeks after surgery,
the bladder is filled with contrast medium,
the Foley catheter is removed and voiding
cystourethrography is obtained.
©
JOURNAL COMPILATION
©
2009 THE AUTHORS
2009 BJU INTERNATIONAL
ONE-SIDED ANTERIOR URETHROPLASTY
FIG. 5. Foley 16 F silicone grooved catheter is inserted.
b
a
stricture was previous urethral
instrumentation. The patient developed a
complete stricture recurrence requiring a
suprapubic tube for acute urinary retention
8 months after surgery and a definitive
perineal urethrostomy was made. Another
failure was in as patient (41-years-old) with
a panurethral stricture (13 cm) due to
lichen sclerosus. The patient developed a
nonobliterative fibrous ring at the proximal
anastomosis and an internal urethrotomy was
made, with a successful outcome at the
preliminary short follow-up.
DISCUSSION
FIG. 6. The urethra is rotated to its original position thus covering the oral graft.
b
a
RESULTS
The overall mean (range) follow-up was
22 (12–55) months. Clinical outcome was
considered a failure when any postoperative
instrumentation was needed, including
dilatation. In all patients, postoperative
voiding cystourethrography was performed
3 weeks after surgery. Uroflowmetry and
urine culture were repeated every 4 months in
the first year and annually thereafter. When
©
symptoms of decreased force of stream were
present and uroflowmetry was less than
14 mL/s, urethrography, urethral ultrasound
and urethroscophy were performed.
Of the 24 patients, 22 (92%) had a successful
outcome and two (8%) were failures. One
failure was in a patient (73-years-old)
with a bulbar urethral stricture (5.5 cm)
recurring following prior oral graft ventral
urethroplasty. The cause of the primary
In the original dorsal onlay techniques the
urethra is circumferentially mobilized form
the corpora cavernosa to better expose its
dorsal surface and to spread fix the graft over
the underlying albuginea [5,6]. In 2008,
Barbagli et al. [8] showed that the dorsal
urethral surface could be easily approached
leaving the bulbospongiosum muscle and the
central tendon of the perineum intact, thus
also preserving the branches of the perineal
nerves from surgical injury.
The bulbospongiosum muscle is primarily
responsible for ejaculation because rhythmic
contractions of this muscle and other perineal
muscles expel semen from the urethra and
probably have an important role in expelling
urine, avoiding urine sequestration in the
large urethral bulb after micturition [8]. Yang
and Bradley [9] illustrated the role of the
perineal nerve in bulbospongiosum muscle
contractions and suggested that ejaculatory
disorders might result from disruption of one
or more of the reflex pathways providing
innervation of the bulbospongiosum muscle.
These disorders may manifest as decreased
force of semen expulsion and low
semen volume caused by inefficient
bulbospongiosum contractility [9]. Yucel and
Baskin [10] showed that perineal nerves
innervate the bulbospongiosum muscle and
send out fine branches that penetrate the
corpus spongiosum, mainly in the bulbar area.
The perineal nerves may be injured during a
bulbar urethroplasty performed according to
the standard procedures [8]. During dissection
of the central tendon of the perineum, the
perineal nerves are most likely to be damaged
upon emergence from the ischiorectal fossa,
or when the bulbospongiosum muscle is fully
divided along the midline, the fine branches
of the perineal nerves penetrating into the
2009 THE AUTHORS
JOURNAL COMPILATION
©
2009 BJU INTERNATIONAL
11 5 3
K U L K A R N I ET AL.
corpus spongiosum may be damaged [8].
Moreover, the perineal nerve branches may
be damaged by incorrect or excessive use
of cautery [8]. For these reasons, bulbar
urethroplasty should be performed using a
conservative approach [8].
FIG. 7. At the end of the procedure, the urethra is fixed on the left side, leaving the lateral blood supply to the
urethra, the bulbospongiosum muscle and the central tendon of perineum intact on the opposite side.
b
a
Circumferential mobilization of the urethra,
as suggested in the original dorsal onlay
graft technique [5,6], severs the vascular
connections between the corpus
spongiousum and the tunica albuginea, and
the lateral vascular connection between the
urethra and the superficial perineal tissue
on both sides. This vascular supply to the
urethra may be compromised in patients
who had undergone prior failed
urethroplasty or in patients with full-length
anterior urethral strictures due to extensive
spongiofibrosis. We realize that in
performing dorsal placement of the graft
in the albuginea, the full circumferential
dissection of the urethra is unnecessary and
may compromise the residual blood supply
to the urethra.
Initially (2004), we selected this new onesided anterior urethroplasty for patients with
prior failed urethroplasty (six cases) or in
patients with full-length anterior urethral
strictures (12 cases) and, subsequently, we
also extended the use of this technique to
patients with long bulbar urethral strictures
who had not undergone prior urethroplasty
(six cases). In our previous experience, onestage bulbar urethroplasties using standard
procedures showed an 83.5% success
rate and the dorsal oral mucosal graft
urethroplasty showed a 77.3% success rate
[11]. In the present preliminary series of
patients using a new vascular, muscle and
nerve-sparing procedure, the success rate
was 92%. The factors currently reported as
influencing the success rate of any kind of
urethroplasty are: patient age, cause of
stricture, length and previous treatments
[11,12]. Our reports have shown that these
factor have no effect on the success rate,
suggesting that other factors (possibly
vascular and neurogenic urethral injury) may
play an important role in determining
stricture recurrence [11,12]. The preservation
of the one-sided vascular supply to the
urethra and its entire muscular and
neurogenic support represents a slight but
significant step toward perfecting the surgical
technique of urethral reconstruction, using
a minimally invasive approach. In 2006,
Eltahawy et al. [13] described a new vessel-
11 5 4
FIG. 8. A, By invaginating the penis into the perineal incision, the penile urethra is dissected only along the
left side, from the corpora cavernosa up to the coronal sulcus. B, The first oral mucosa graft is sutured to the
dorsal edge of the meatus and pushed inside the opened penile urethra and fixed to the corpora cavernosa.
Another oral mucosa graft is applied to the corpora cavernosa opposite the bulbar urethra.
b
a
sparing excision and primary anastomosis of
the urethra, preserving the arteries of the
bulb. Further studies on a large series of
patients are necessary to confirm that
preservation of the one-sided lateral
vascular supply to the urethra and its entire
muscular and neurogenic support reduces
the incidence of stricture recurrence and
postoperative complications [8]. Data
collection is ongoing.
©
JOURNAL COMPILATION
©
2009 THE AUTHORS
2009 BJU INTERNATIONAL
ONE-SIDED ANTERIOR URETHROPLASTY
6
CONFLICT OF INTEREST
None declared.
REFERENCES
1
2
3
4
5
©
Duplay S. Sur le traitment chirurgical de
l’hypospadias et de l’epispadias. Arch Gen
Med 1880; 145: 257–74
Browne D. An operation for hypospadias.
Proc R Soc Med 1949; 42: 466–8
Monseur J. [Widening of the urethra
using the supra-urethral layer]. J Urol
(Paris) 1980; 86: 439–49
Morey AF, McAninch JW. When and
how to use buccal mucosal grafts in adult
bulbar urethroplasty. Urology 1996; 48:
194–8
Barbagli G, Selli C, Tosto A, Palminteri
E. Dorsal free graft urethroplasty. J Urol
1996; 155: 123–6
Kulkarni SB, Kulkarni JS, Kirpekar DV.
A new technique of urethroplasty for
balanitis xerotica obliterans. J Urol 2000;
163 (Suppl.): 352 (abstract V31)
7 Asopa HS, Garg M, Singhal GG, Singh L,
Asopa J, Nischal A. Dorsal free graft
urethroplasty for urethral stricture by
ventral sagittal urethrotomy approach.
Urology 2001; 58: 657–9
8 Barbagli G, De Stefani S, Annino F,
De Carne C, Bianchi G. Muscle- and
nerve-sparing bulbar urethroplasty:
a new technique. Eur Urol 2008; 54: 335–
43
9 Yang CC, Bradley WE. Somatic
innervation of the human bulbocavernous
muscle. Clin Neurophysiol 1999; 110:
412–8
10 Yucel S, Baskin LS. Neuroanatomy of the
male urethra and perineum. BJU Int 2003;
92: 624–30
11 Barbagli G, Guazzoni G, Lazzeri M. Onestage bulbar urethroplasty: retrospective
analysis of the results in 375 patients. Eur
Urol 2008; 53: 828–33
12 Barbagli G, De Angelis M, Romano
G, Lazzeri M. Long-term followup of
bulbar end-to-end anastomosis: a
retrospective analysis of 153 patients in a
single center experience. J Urol 2007; 178:
2470–3
13 Elthahawy EA, Virasoro R, Jordan
GH. Vessel sparing excision and
primary anastomosis of the urethra.
J Urol 2006; 175 (Suppl.): 104 (abstract
315)
Correspondence: Massimo Lazzeri,
Department of Urology, Santa Chiara Hospital,
P.zza Indipendenza 11, 50129 Florence,
Italy.
e-mail: [email protected]
2009 THE AUTHORS
JOURNAL COMPILATION
©
2009 BJU INTERNATIONAL
11 5 5