Distal Penile Circular Fasciocutaneous Flap For Complex Anterior Urethral Strictures

Main Category: Urology / Nephrology
Also Included In: Men's health
Article Date: 12 Oct 2007 - 0:00 PDT

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UroToday.com- Complex anterior urethral strictures represent challenging cases even for the experienced reconstructive urologist. These repairs usually require tissue transfer in the form of free grafts, such as buccal mucosa or pedicled flaps. In a recent surgery illustrated entry from the July 2007 issue of BJU Int., Jill Buckley and Jack McAninch from San Francisco revisit and describe the technique of circular fasciocutaneous flap (FCF) urethroplasty for use in the repair of complex anterior urethral strictures.

In this review, which is accompanied by wonderfully detailed illustrations by Stephan Spitzer, the technique of the circular FCF is described. Patient selection focuses on length and location of the stricture and the availability of healthy foreskin in the uncircumcised male or distal penile shaft skin in the circumcised male, this hairless skin works very well for these repairs. In conditions such as balanitis xerotica obliterans (BXO) this penile skin may not exhibit characteristics that will lead to successful repair. All patients should be evaluated with retrograde and voiding urethrography to define urethral stricture anatomy.

Patient positioning is dependent on location of the stricture as this technique can be utilized for distal penile strictures (in which case a supine position is chosen) and can be carried all the way back to the proximal bulbar urethra (in which case a high lithotomy position is selected). Proper surgical development of the FCF requires two planes of dissection. Two circumferential skin incisions are made starting at the coronal margin and placed 20 mm apart. Superficially, the dissection is between the dartos fascia and tunica dartos and deeper, it is below Buck's fascia as it is the fascial support for the tunica dartos. The tunica dartos carries the blood supply to the island of penile skin and is supported by Buck's fascia.

After dropping the penile skin and flap down to the base of the penis the stricture is localized by intubating the meatus with a 20 F red rubber catheter and making a ventral urethrotomy where the catheter stops- this signifies the distal most aspect of the stricture. The urethrotomy is then continued until normal caliber urethra is encountered. This is documented by calibration with bougie-a-boules. Cystoscopy is then performed to further document the absence of further strictures. The circular flap is then split ventrally and rotated to one side. The flap is then tailored under stretch to the length of the stricture. The flap is then run from apex to apex on one side, a urethral catheter placed, and then the flap is splayed over the catheter and run from apex to apex with fine 6-0 suture. The penile skin is then brought back up to the coronal margin and closed with interrupted 4-0 absorbable suture. An occlusive pressure dressing in applied and the penis is fixed to the abdominal wall to minimize swelling.

The catheter is maintained for 3 weeks at which point a VCUG is performed to document adequate healing. Slight ventral penile bowing and torque can be seen for up to 3 months postoperatively. Erections aid in the disappearance of these issues. Success rates of 85-90% can be expected and excellent cosmetic results are the norm.

Buckley J and McAninch J

BJU Int. 100(1):221-31, July 2007
doi:10.1111/j.1464-410X.2007.07027.x

Reported by UroToday.com Contributing Editor Michael J. Metro, M.D

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