Non-transecting bulbar urethroplasty

Abstract

Excision and end-to-end anastomosis (EPA) has been the preferred urethroplasty technique for short bulbar strictures and is associated with an excellent functional outcome. Driven by concerns over the potential morbidity associated with dividing the urethra, therefore compromising spongiosal blood flow, as well as spongiofibrosis being superficial in the majority of non-traumatic bulbar strictures, the non-transecting technique for bulbar urethroplasty has been developed with the aim of achieving the same success as EPA without the morbidity associated with transection. This manuscript highlights the fundamental principles underlying the ongoing debate-transection or non-transection of the strictured bulbar urethra? The potential advantages of avoiding dividing the corpus spongiosum of the urethra are discussed. The non-transecting anastomotic procedure together with its various modifications are decribed in detail. Our experience with this technique is presented. Non-transecting excision of spongiofibrosis with preservation of well vascularised underlying spongiosum provides an excellent alternative to dividing the urethra during urethroplasty for short non-traumatic proximal bulbar strictures.

Keywords: Anterior urethral strictures; urethral reconstruction; urethroplasty.

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1

A typical idiopathic bulbar stricture; short, sharp and at the junction of the proximal and middle thirds; likely congenital in origin.

Figure 2

A midline perineal incision is made (A) and deepened down to the bulbar urethra which is mobilised dorsally off the tunica albuginea of the corpora cavernosa (B). A dorsal stricturotomy is made by cutting down onto a catheter in the urethra at the stricture site (C) and stay sutures positioned (D). A gorget facilitates extension of the stricturotomy into healthy urethra on either side of the stricture (E).

Figure 3

Dorsal stricturotomy of a short membrane-like stricture: operative photograph (A); diagrammatic representation (B); the stricture is not excised but the epithelial defects on either side of the preserved strip are sutured (C). The dorsal stricturotomy closed transversely as in Figure 4 [reproduced with permission from (27)].

Figure 4

(A) Diagram showing appearance following excision of epithelial and spongiofibrotic components of the stricture. Underlying spongiosum is visible; (B) the healthy mucosal edges adjacent to the excised spongiofibrosis are anastomosed in a tension-free fashion; (C) the longitudinal dorsal stricturotomy is closed in a horizontal plane [reproduced with permission from (27)].

Figure 5

Radiological appearance before and after (A,B) NTABU and (C,D) ANTABU. Even though the urethral calibre is maintained after NTABU, there is a characteristic buckled appearance of the ventral aspect of the urethra resulting from shortening of the dorsal aspect produced by the stricturoplasty.

Figure 6

Radiological appearance (A) before and (B) after stricturoplasty for short, sharp, proximal bulbar strictures.