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Surgical Tips and Tricks During Urethroplasty for Bulbar Urethral Strictures
Focusing on Accurate Localisation of the Stricture: Results from a Tertiary
Centre

Article  in  European Urology · January 2015

DOI: 10.1016/j.eururo.2014.12.029 · Source: PubMed

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Surgery in Motion

Surgical Tips and Tricks During Urethroplasty for Bulbar Urethral

Strictures Focusing on Accurate Localisation of the Stricture:
Results from a Tertiary Centre

Tricia L.C. Kuo *, Suresh Venugopal, Richard D. Inman, Christopher R. Chapple

Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK

Article info Abstract

Article history: Background: There are several techniques for characterising and localising an anterior
Accepted December 13, 2014 urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and
endoscopy. However, these techniques have some limitations. The final determinant is
intraoperative assessment, as this yields the most information and defines what surgical
Keywords: procedure is undertaken.
Urethral stricture Objective: We present our intraoperative approach for localising and operating on a
Operative technique urethral stricture, with assessment of outcomes.
Design, setting, and participants: A retrospective review of urethral strictures operated
Urethroplasty
was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All
patients were referred to a tertiary centre and operated on by two urethral reconstruc-
Please visit tive surgeons.
Surgical procedure: Intraoperative identification of the stricture was performed by
www.europeanurology.com and cystoscopy. The location of the stricture is demonstrated externally on the urethra
www.urosource.com to view the by external transillumination of the urethra and comparison with the endoscopic
accompanying video. picture. This is combined with accurate placement of a suture through the urethra,
at the distal extremity of the stricture, verified precisely by endoscopy.
Outcome measures and statistical analysis: Clinical data were collected in a dedicated
database. Intraoperative details and postoperative follow-up data for each patient were
recorded and analysed. A descriptive data analysis was performed.
Results and limitations: A representative group of 35 male patients who had surgery
for bulbar stricture was randomly selected from January 2010 to December
2013. Mean follow-up was 13.8 mo (range 2–43 mo). Mean age was 46.5 yr (range
17–70 yr). Three patients had undergone previous urethroplasty and 26 patients had
previous urethrotomy or dilatation. All patients had preoperative retrograde ure-
thrography and most (85.7%) had endoscopic assessment. The majority of patients
(48.6%) had a stricture length of >2–7 cm and 45.7% of patients required a buccal
mucosa graft. There were no intraoperative complications. Postoperatively, two
patients had a urinary tract infection. All patients were assessed postoperatively
via flexible cystoscopy. Only one patient required subsequent optical urethrotomy
for recurrence.
Conclusions: Our intraoperative strategy for anterior urethral stricture assessment
provides a clear stepwise approach, regardless of the type of urethroplasty eventually
chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ven-
tral, or augmented roof strip). It is useful in all cases by allowing precise localisation of
the incision in the urethra, whether the stricture is simple or complex.

* Corresponding author. Department of Urology, Singapore General Hospital, Outram Road,

Singapore 169608, Singapore. Tel. +65 81231004.
E-mail address: kuolct@yahoo.com (T.L.C. Kuo).

http://dx.doi.org/10.1016/j.eururo.2014.12.029
0302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
 EUROPEAN UROLOGY 67 (2015) 764–770 765

Patient summary: We studied the treatment of bulbar urethral strictures with different
types of urethroplasty, using a specific technique to identify and characterise the length of
the stricture. This technique is effective, precise, and applicable to all patients undergoing
urethroplasty for bulbar urethral stricture.
# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

1. Introduction At our institution, we often ask patients on intermittent self-

The surgical technique used for anterior urethroplasty
depends on several key factors. These include the char-
acteristics of the stricture, patient comorbidities, urethral
and penile length, and surgeon preference. Stricture
characteristics that influence the type of reconstruction
include stricture length, degree of spongiofibrosis, anatomic
position, aetiology, and previous treatment. Most means of
assessment are preoperative, such as radiologic (retrograde
urethrogram, RUG), ultrasonographic, and endoscopic
(cystoscopy and urethroscopy) methods, and can be
difficult to interpret and relate to operative findings. The
above techniques are useful, but ultimately the reconstruc-
tion is based on intraoperative findings.
We present here our technique for precise intraoperative
assessment of an anterior urethral stricture during ure-
throplasty, and a retrospective review of outcomes for a
representative group of patients.
dilatation (ISD) to stop this procedure a couple of weeks before surgery.
Another urethrogram after ISD cessation and just before surgery can also
aid in assessing stricture length.
2.2.2. Perioperative endoscopic evaluation and placement of a guide
wire
A rigid cystoscope is inserted into the urethra for visualisation of the
junction between healthy pink mucosa and the abnormal white
appearance of spongiofibrosis. This aids in localisation of the stricture.
A guide wire passed through the stricture (Fig. 2) facilitates later
dissection and identification of the urethral lumen. The guide wire is
secured to the foreskin with a silk tie to prevent displacement.
2.2.3. Perineal dissection
A vertical midline perineal incision is used. After incision of the Colles
fascia, a ring retractor is placed and yields excellent exposure. The
bulbospongiosus muscle is divided and retracted laterally to expose the
urethra. The urethra is circumferentially mobilised. Further mobilisation
along the urethral length proximally and distally allows for later tension-
free anastomosis/augmentation.

2. Patients and methods 2.2.4. Localisation and characterisation of the stricture

Passage of a metal sound through the tight stricture to the proximal
2.1. Study population extent is unwise since this dilates the stricture and may cause urethral
trauma, which makes identification of the stricture site difficult. In fact,
Data were retrospectively collected from the medical records for a
representative group of 35 patients who underwent bulbar or
bulbomembranous urethroplasty at a tertiary centre. Our centre carries
Table 1 – Patient demographics, clinical presentation, and
out more than 100 urethroplasties a year. A heterogeneous representa-
previous interventions and treatment
tive cohort was selected to show the flexible application of our surgical
technique. All patients were operated on by two dedicated urethral Parameter Value
reconstructive surgeons between January 2010 and December 2013. All
Patients (n) 35
patients were extensively counselled on surgical and anaesthetic risks.
Mean age, yr (range) 46.5 (17–70)
Informed consent was obtained.
Mean follow-up, mo (range) 13.8 (2–43)
Preoperative assessment included medical history, physical exami- Clinical presentation, n (%)
nation, and routine laboratory evaluation. All patients underwent Retention 12 (34.2)
preoperative retrograde urethrography and 30 patients (85.7%) had Obstructive symptoms 24 (68.6)
endoscopic assessment. Endoscopic evaluation was only performed in (eg, poor stream,
dribbling, hesitancy,
selected cases in which the RUG was not clear.
incomplete emptying)
Patient demographics, symptoms at presentation, and history of
Storage symptoms 2 (5.7)
previous interventions and treatment are shown in Table 1. Pain 6 (17.1)
Urinary tract infection 4 (11.4)
2.2. Surgical technique Haematuria 4 (11.4)
Possible cause, n (%)
History of lichen sclerosis 5 (14.2)
2.2.1. Preoperative preparation and patient positioning
Trauma 3 (8.6)
Under general anaesthesia with broad-spectrum antibiotic cover, the
Previous endoscopic 11 (31.4)
patient is placed in a lithotomy position, with the legs flexed at 308. procedure (eg, transurethral
Trendelenburg tilting (head down) of the patient facilitates later radical prostatectomy,
dissection. Routine thromboembolic prophylaxis with compression cystoscopy)
stockings and compressive leg devices is used in all cases. Previous catheterisation 4 (11.4)
A preoperative RUG for a representative patient shows a bulbar Previous treatment/intervention, n (%)
Urethroplasty 3 (8.6)
stricture and slight narrowing at the mid-penile urethra (Fig. 1). Flexible
Optical urethrotomy or dilatation 27 (77.1)
cystoscopy and urethroscopy revealed that the area in the penile urethra Intermittent self-dilatation 10 (28.6)
was simply a mucosal fold.
766 EUROPEAN UROLOGY 67 (2015) 764–770
[(Fig._1)TD$IG]
Fig. 1 – Retrograde urethrogram showing a tight bulbar urethral
stricture.
patients are often asked to halt intermittent self dilatation for 1–2 wk
before surgery for the same reason.
With severe stenosis and retention, there is often a suprapubic
catheter (SPC) present. The surgeon may then pass a flexible cystoscope
or metal sound via the suprapubic tract. However, in the absence of a SPC
and tract, the distal extent of the stricture can easily be visualised with a
transurethral cystoscope. This is identified externally by transillumina-
tion of the urethra. Transillumination may be challenging on approach-
ing the posterior urethra. However, once the urethra is suitably exposed,
then it is usually possible to identify the stricture on the dorsal aspect.
A stay suture may be placed at the distal extent. This can easily be
accomplished with the assistant holding the cystoscope and the surgeon
compressing the exposed urethra to verify the exact spot. The suture
traverses the ventral aspect of the urethra through the entire thickness of
the urethra into the lumen at the precise junction between normal
mucosa and the diseased stricture. This can be verified by direct
visualisation both through the cystoscope and externally (Fig. 3).
With this suture in place, the surgeon is then able to fully assess the
position of the stricture. Use of a suture allows accurate incision of the
stricture. The suture is placed within 1 mm of the stricture, and any
potential trauma to this is absorbed on subsequent spatulation. This
approach is less harmful than incising in the wrong place.
2.2.5. Stricturotomy and decision-making process
The stricture is opened either laterally or dorsally between the 9- and
[(Fig._2)TD$IG]
3-o’clock positions where the corpus spongiosum is thinnest. This
Fig. 2 – A guide wire is placed through the stricture.
incision into the lumen of the stricture is facilitated by positioning of stay
sutures through the full thickness of the urethra. These stay sutures allow
rotation of the urethra, whether for a ventral, dorsal, or laterally positioned
augmentation. If a guide wire is in place, the lumen can be clearly identified
and the urethra opened proximally through the stricture until normal
urethra is reached, thereby identifying the location, length, and extent of
the spongiofibrosis. It is then possible to plan the reconstructive
procedure, whether anastomotic (disconnected or Heineke-Mikulicz) or
augmentation (dorsal, ventral, or augmented roof strip).
The length of the stricture is measured with a tapeline when
considering augmentation. The factors that determine whether the
stricture length can be overcome with an anastomotic approach are the
experience of the surgeon and the anatomy of the patient [1].
As a rule, the urethra is calibrated at 32F proximally and 28F distally
in uncomplicated cases. This arbitrarily calibrates the size of the lumen
and allows subsequent passage of surgical instruments such as
cystoscopes.
2.2.6. SPC placement
Before closure of the urethra, an SPC is placed in all patients. We
recommend use of an SPC in our patients, as they usually travel some
distance and it provides a safety measure. In addition, an SPC allows
instillation of contrast for subsequent voiding cystourethrograms. The
contrast can be voided around the urethral catheter.
A Turner-Warwick Hey Groves urethral staff is placed via the open
perineal wound into the urethra and passed into the bladder, as shown in
Figure 4A. A cut in the skin in the suprapubic region is made to allow
the emergence of the metal tip of the staff. A nylon stitch is tied to a 16F
Foley catheter (Fig. 4B). The SPC is brought down into the bladder by
simply pulling back on the staff (Fig. 4C). Cystoscopy is then performed
to push the SPC into the bladder for direct visualisation of the catheter
balloon in the bladder. A clip is used to secure the long end of the nylon
stitch. Then the long end of the nylon stitch is tied to a single 14F-lumen
Porges urethral catheter, introduced from the penile urethra (Fig. 4D).
The nylon stitch is secured to the suprapubic region with beads and
small metallic clamps (Fig. 4E). The urethral catheter is therefore
attached to a suture quite separate from the SPC.
Using this method, it is rare for a urethral catheter to be dislodged in
our experience. The placement of the SPC and urethral catheter on a
nylon suture also means that there is no inflated balloon to disrupt the
anastomosis.
2.2.7. Dressings and securing the catheters
The layers of the perineal wound are closed carefully to eliminate any
dead space and prevent haematomas. We do not routinely place a drain.
A compression dressing is applied with wool and molyknickers. Finally,
both catheters are taped to the anterior abdominal wall to prevent
dislodgement and pulling on the wound during recovery.
2.3. Postoperative course
A standard postoperative protocol is used in all cases. Intravenous broad-
spectrum antibiotics are continued for 3 d. Thereafter, patients are given
oral antibiotics until the catheters are removed. Patients are ambulated
on postoperative day 1. Compressive dressings are kept in place for 4 d.
Previously, patients were admitted for 2 wk. However, we have since
modified our protocol and now they are discharged on the fourth
postoperative day.
2.4. Postoperative follow-up
The patient is brought back 2 wk later for a postoperative urethrogram
via the SPC. If there are no leaks, the urethral catheter is then removed
 EUROPEAN UROLOGY 67 (2015) 764–770 767
[(Fig._3)TD$IG]

Fig. 3 – (A) Stay sutures visualised endoscopically after (B) placement at the distal end of the stricture. (C) Transillumination of the urethra to show the
site of the stricture (yellow arrow).

and the SPC is closed with a spigot. Once the patient is voiding well with
acceptable residual volumes, the SPC is removed.
Subsequent follow-up is conducted at 6 wk, 3 mo, 6 mo and 1 yr
postoperatively and involves flexible urethroscopy.
2.5. Data analysis
Clinical data were collected in a dedicated database. Intraoperative
details and postoperative follow-up data for each patient were recorded
and analysed. A descriptive data analysis was performed.
for recurrence. On follow-up with flexible urethroscopy,
three patients had a paper-thin diaphragm or web at the
anastomotic junction. This was not a recurrence or
restricture and was easily treated with either dilatation
under local anaesthesia or endoscopic incision under
general anaesthesia if the patient could not tolerate the
discomfort. These diaphragms or webs did not recur
subsequently and were most likely due to local healing.
4. Discussion

3. Results The reconstructive surgical technique for urethroplasty

is unpredictable. Success depends on the ability of the
Intraoperative findings are listed in Table 2. The majority of surgeon to adopt or adapt procedures according to findings
patients had a stricture length of >2–7 cm and 45.7% of
patients required buccal mucosa graft. There were no
intraoperative complications. In all substitution/augmenta- Table 2 – Intraoperative findings and results
tion cases, buccal mucosa was used. In addition, all grafts
Parameter Patients, n (%)
were placed dorsally. This technique was popularised by
Barbagli et al [2] and is a modification of the Monseur Stricture length
<1 cm 1 (2.9)
technique [3]. We advocate dorsal or lateral placement of the
1–2 cm 16 (45.7)
graft, as that is where the corpus spongiosum is thinnest. 2–7 cm 17 (48.6)
Concomitant procedures included correction of chordee >7 cm 1 (2.9)
for one patient and glanduloplasty for another. Urethroplasty technique
Anastomosis 19 (54.3)
Two patients had a postoperative urinary tract infection. Substitution/augmentation 16 (45.7)
Only one patient required subsequent optical urethrotomy
768 EUROPEAN UROLOGY 67 (2015) 764–770
[(Fig._4)TD$IG]

Fig. 4 – Suprapubic catheter placement.

noted during the course of the operation. This is the so-
called TITBAPIT principle of reconstructive surgery—take it
to bits and put it together [4].
A RUG is the standard preoperative investigation for
further delineation of a stricture. A consecutive ascending
and voiding cystourethrogram should also be carried out,
the latter to better define the proximal limit of the stricture
and assess the external sphincter complex and bladder
neck. However, it is well known that these radiographic
studies often underestimate stricture length because they
 EUROPEAN UROLOGY 67 (2015) 764–770
are performed in an oblique position in relation to the
anteroposterior x-ray beam, resulting in a shorter projected
view of the stricture [5,6]. In addition, in the case of very
tight strictures, chronic high-pressure voiding results in
dilatation of the proximal segment. This segment is
therefore also abnormal, so the stricture appears to be
shorter than it really is. Hence, RUG is limited in its ability to
accurately reveal urethral stricture length, and the location
or extent of periurethral disease [5–7].
In view of the limitations of radiological evaluation, some
have proposed ultrasonographic evaluation. In addition to
ascertaining the stricture length and location, ultrasound can
also provide information regarding the degree of spongiofi-
brosis and concomitant pathology, such as diverticulae,
fistulae, stones, false passages, and periurethral abscesses
[5,6,8]. Retrospective reviews have shown that intraopera-
tive ultrasound changed the surgical approach in 19% of
cases, and was integral in deciding between two possible
approaches for 26% of patients [9]. However, interpretation of
ultrasonography of the urethra is also operator-dependent
and results may vary between individuals. Therefore,
ultrasonography should be an adjunct investigational tool
and cannot replace a formal intraoperative assessment.
The feasibility of performing Heineke-Mikulicz or discon-
nected primary anastomosis versus augmentation urethro-
plasty depends on the stricture characteristics. Hence,
precise anatomic knowledge of the stricture is essential,
and is critical in allowing a borderline length stricture of
<2.3–3.0 cm to be treated anastomotically rather than by
augmentation, as the latter has a lower long-term success
rate. Ideally, the feasibility is assessed and predicted
preoperatively as far as possible, but this is often not possible
because of the limitations of radiological investigations. In all
cases, intraoperative assessment and localisation are the final
determinants of how a stricture is reconstructed.
An alternative and ingenious method of delineating the
proximal extent of a stricture is the use of a small 4–5F
Fogarty vascular catheter as an alternative to a guide wire.
The balloon catheter acts as an intraluminal guide and can
be inflated to the desired balloon size (eg, 30F) in the
proximal lumen [10].
The surgical tips and tricks described here using a
consecutive approach have several advantages compared
to existing strategies of cutting down on a sound. There is
precise visual demarcation of the junction between
abnormal and normal mucosa. This is particularly applica-
ble to treatment of recurrent strictures. Multiple previous
endoscopic manipulations and treatment are associated
with a more difficult definitive open repair and a
potentially poorer outcome [11]. Other authors suggest
that the failure rate is not significantly higher for patients
with previous endoscopic treatments undergoing open
surgical repairs, but the urethroplasty may be more
complex [12,13] and certainly the success rate is better
for anastomotic than for augmentation procedures. Some-
times the reason for failure of the first urethroplasty is
technical, as the surgeon does not get sufficiently proximal.
Evidence of this can be seen in patients with recurrence at
the proximal anastomotic ring.
769
We acknowledge that our review is retrospective.
However, it is difficult to carry out randomised controlled
trials in a heterogeneous clinical group of patients. Our
main intent in this paper was to focus on the surgical
technique. Equipment and facilities may be an issue in some
centres, and this is a caveat to our technique.
Terminology and standardisation previously agreed and
published as a consensus statement [14] and as guidelines
by the International Consultation on Urological Diseases
after the Société Internationale d’Urologie meeting in
October 2010 were adhered to in this article [15].
Reconstructive urology requires application of a set of
well-defined techniques used in an appropriate sequence
depending on findings at the time of surgery. The sequence
used will depend on what is found after the urethral
stricture has been clearly characterised.
5. Conclusions
In summary, our intraoperative approach and strategy for
anterior urethral stricture assessment provide a clear
stepwise guide, regardless of which type of urethroplasty
is eventually chosen (anastomotic or augmentation, dorsal
or ventral, or augmented roof strip). In this paper and video,
we clearly identify the steps to characterise a stricture and
subsequently reconstruct it.
Author contributions: Tricia L.C. Kuo had full access to all the data in the
study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Kuo, Venugopal, Inman, Chapple.
Acquisition of data: Kuo, Venugopal.
Analysis and interpretation of data: Kuo, Venugopal, Inman, Chapple.
Drafting of the manuscript: Kuo, Venugopal, Inman, Chapple.
Critical revision of the manuscript for important intellectual content: Kuo,
Venugopal, Inman, Chapple.
Statistical analysis: Kuo, Venugopal, Inman, Chapple.
Obtaining funding: None.
Administrative, technical, or material support: Kuo, Venugopal, Inman,
Chapple.
Supervision: Kuo, Venugopal, Inman, Chapple.
Other: None.
Financial disclosures: Tricia L.C. Kuo certifies that all conflicts of interest,
including specific financial interests and relationships and affiliations
relevant to the subject matter or materials discussed in the manuscript
(eg, employment/affiliation, grants or funding, consultancies, honoraria,
stock ownership or options, expert testimony, royalties, or patents filed,
received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
Acknowledgments: We are grateful to the Department of Medical
Illustrations, Royal Hallamshire Hospital, Sheffield, UK.
Appendix A. Supplementary data
The Surgery in Motion video accompanying this article can
be found in the online version at http://dx.doi.org/10.1016/j.
eururo.2014.12.029 and via www.europeanurology.com.
770 EUROPEAN UROLOGY 67 (2015) 764–770
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