Joshi Pankaj M, Bandini Marco, Bafna Sandeep, Sharma Vipin, Patil Amey, Bhadranavar Shreyas, Yepes Christian, Barbagli Guido, Montorsi Francesco, Kulkarni Sanjay B
Kulkarni Reconstructive Urology Center, Pune, India.
Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Eur Urol Open Sci. 2021 Nov 25;35:21-28. doi: 10.1016/j.euros.2021.10.009. eCollection 2022 Jan.
Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra.
To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction.
Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study.
The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula.
Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure.
We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5-8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5-26 ml/min). The median follow-up was 25 mo (IQR 10-30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique.
In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra.
Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.
对于尿道狭窄几乎完全闭塞的患者，分期手术或会阴尿道造口术是仅有的可行替代方案，在此类患者中，移植加皮瓣尿道成形术正逐渐得到更多应用。然而，移植加皮瓣尿道成形术主要用于涉及阴茎尿道的狭窄。
报告我们采用移植加皮瓣尿道成形术进行球部和阴茎球部尿道重建的经验。
设计、场所和参与者：2014年1月至2020年6月期间，将近端或完全闭塞的长（>4cm）球部或阴茎球部尿道狭窄且需要移植加皮瓣尿道成形术的患者纳入本研究。
必要时通过会阴切口和阴茎内翻显露球部和阴茎尿道。从脸颊、舌部或包皮皮肤获取移植物，缝盖于海绵体上以重建新尿道的背侧板。阴茎筋膜皮瓣重建新尿道的腹侧板。将海绵体瓣覆盖于新尿道上以防止憩室形成。
术后任何器械操作需求定义为原发性失败。存在梗阻症状或最大尿流率（Qmax）低于10ml/s，无论是否需要器械操作，均定义为继发性失败。
我们确定了15例符合纳入标准的患者。狭窄长度中位数为7cm（四分位间距[IQR]5-8cm）。脸颊内侧是获取移植物的首选部位（53.3%）。术后30天内未记录到Clavien-Dindo≥III级围手术期并发症。拔除导尿管时Qmax中位数为23ml/min（IQR 21.5-26ml/min）。中位随访时间为25个月（IQR 10-30个月）。原发性成功率为86.7%（13/15），继发性成功率为73.3%（11/15）。创伤后狭窄是该技术的禁忌证。
在转诊中心，移植加皮瓣尿道成形术对于近端或完全闭塞的长（>4cm）尿道狭窄患者是一种可行的选择。我们的研究表明，该选择对于主要累及球部尿道的狭窄也可行。
对于近端或完全闭塞的球部尿道狭窄患者，会阴尿道造口术应被视为最后选择。如今，移植加阴茎筋膜皮瓣增大术丰富了我们球部尿道重建的手段。
