BMG

URETHROPLASTY
Anatomy
 The corpora cavernosa are not separate structures but constitute
a single space with free communication through an incompetent
midline septum that becomes more complete toward the base of the
penis.
 This erectile tissue contains arteries, nerves, muscle fibers, and
venous sinuses lined with flat endothelial cells, and these features fill
the corpora cavernosa, making its cut surface look like a sponge.
 This tissue is separated from the tunica albuginea by a thin layer of
areolar connective tissue.
 At its base, the penis is supported by two ligaments, composed
primarily of elastic fibers that are continuous with the fascia of the
penis
 Posterior to this attachment, the right and left corpora cavernosa
diverge, and the corpus spongiosum broadens between the two
crura to form the bulbospongiosus (bulb)
Classification of urethra
1. 1. The fossa navicularis is contained within the spongy erectile tissue of the glans penis
and terminates at the junction of the urethral epithelium with the skin of the glans.
1. lined with stratified squamous epithelium.
2. 2. The penileor pendulous urethralies distal to the investment of the ischiocavernosus
musculature but is invested by the corpus spongiosum and maintains a constant lumen size
roughly centered in the corpus spongiosum.
1. is lined with simple squamous epithelium.
3. The bulbous urethra is covered by the midline fusion of the ischiocavernosus
musculature and is invested by the bulbospongiosus of the corpus spongiosum.
1. lies closer to the dorsal aspect of the corpus spongiosum, exiting from its dorsal surface before
the posterior attachment of the bulbospongiosus to the perineal body
2. lined distally with squamous epithelium that gradually changes to the transitional epithelium found in the
membranous urethra as it swings upward
4. The membranous urethra is is surrounded by the external urethral sphincter. This segment of
the urethra is unattached to fixed structures, the distinction of being the only portion of the
male urethra that is not invested by another structure, and is lined with a delicate transitional
epithelium
5. The prostatic urethrais the portion of the urethra that is proximal to the membranous
urethra and is mostly surrounded by the prostatic stromal and glandular tissue. Its
epithelium is continuous with the epithelium of the trigone and bladder
6. The bladder neck is the location of the bladder neck musculature,
 A submucosal layer is noted throughout the length of
the urethra.
 Five “sphincters” are recognized
1. the bladder neck is first.
2. The prostate itself is composed of a muscular stroma.
3. The prostate muscle continues into the membranous
urethra as the external smooth muscle sphincter.
4. The external rhabdosphincter is often referred to as the
external sphincter.
5. In the area of the membranous urethra are the muscles of
recruitment, which are not true sphincters but provide aid with
volitional continence.
 Buck fascia is the tough, elastic layer
immediately adjacent to the tunica
albuginea (see Fig. 40-5). On the superior
aspect of the corpora cavernosa, the deep
dorsal vein, paired dorsal arteries, and multiple
branches of the dorsal nerves are contained
within the envelope of Buck fascia.
 In the midline groove on the underside of the
corpora cavernosa, Buck fascia splitsto
surround the corpus spongiosum
Urethroplasty
 Excision +Primary Anastomotic (EPA)
 Augmented
Graft
Flap
 Augmented –anastomotic
 Transposition
 Staged
PRINCIPLES OF 
RECONSTRUCTIVE SURGERY
 Skin – Epidermis, Dermis(papillary and Reticular layers)
 Oral Mucosa-Mucosa, Lamina P.(papillary and reticular
layers)
 Bladder Mucosa
The issue of desiccation and hypertrophic growth, in the case
of the bladder epithelial graft, has limited its use in the distal
urethra
 All tissue has physical characteristics
extensibility, inherent tension, and the viscoelastic properties of
stress relaxation and creep.
are primarily a function of the helical arrangement of collagen along
with the elastin cross-linkages
 The term graft implies that tissue has been excised and
transferred to a graft host bed, where a new blood supply
develops by a process termed take.
 Take requires approximately 96 hours and occurs in two phases.
Imbibition (Botany word for “to absorb”
○ requires about 48 hrs
○ the graft survives by “drinking” nutrients from the adjacent graft host bed, and
○ the temperature of the graft is less than the core body temperature
Inosculation ( Interwining)
○ also requires about 48 hours and
○ true microcirculation is reestablished in the graft.
○ temperature of the graft increases to core body temperature
 Intradermal plexus(superficial plexus)- at interface
of epidermis with papillary dermis ( lamina.p)
 deep plexus- On the undersurface of the deep
dermal layer or deep lamina.
Contains most of the lymphatics and greater collagen
content than found in the superficial dermal layer.
The deep or reticular dermis is generally thought to
account for the physical characteristics of the tissue.
split-thickness unit
 If a graft is a split-thickness unit, it carries the epidermis or the
covering. The graft also exposes the superficial dermal (intradermal
or intralaminar) plexus.
 The reticular dermis is not carried with it
 superficial plexus comprises small but numerous vessels, which
conveys favorable vascular characteristics to a split-thickness unit.
 The unit has few lymphatics, and the physical characteristics are not
carried, which accounts for the tendency of split-thickness units
to be brittle and less durable.
 It has also been proposed that mesh grafts take readily
because of increased levels of growth factors, possibly as a function
of the slits.
 In general, full-thickness skin grafts are not meshed
Full Thickness Graft
 Contains reticular layer
 In skin, the subdermal plexus is exposed. In most cases, the
plexus is composed of larger vessels that are more
 sparsely distributed. The graft is fastidious in its vascular characteristics
 There is a difference between genital full-thickness skin (penile and
preputial skin grafts) and extragenital full-thickness skin.
This is probably a reflection of the increased mass of the graft in
extragenital skin grafts. This increased mass makes the graft more fastidious,
and the poor results reported with urethral reconstruction with extragenital full-
thickness skin grafts are probably due to poor or ischemic take
The posterior auricular graft (Wolfe graft) is an exception to the rule
concerning extragenital skin. The postauricular skin is thin and overlies the
temporalis fascia and is thought to be carried on numerous perforators
The subdermal plexus of this graft mimics the characteristics of the
intradermal plexus, and the total mass of the graft is more like that of the
split-thickness unit.
 In the bladder epithelial graft, there is a superficial and a deep plexus;
however, the plexuses are connected by many more perforators.
 Bladder epithelial grafts tend to have more favorable vascular characteristics.
 In the case of oral mucosal grafts, there is a panlaminar plexus.
The oral mucosal graft can be thinned, provided that a sufficient amount of deep lamina
is carried to preserve the physical characteristics (see Fig. 40-1B).
 Oral mucosal grafts are thought to have optimal vascular characteristics
 The thinned graft diminishes the total graft mass, while preserving the
physical characteristics and not adversely affecting the vascular
characteristics. The enthusiasm for the buccal mucosal graft seems well
founded.
 The lingual, labial, and buccal grafts all vary in thickness and in substance.
Because the labial mucosal grafts are thin, many surgeons prefer that donor
site for reconstruction of the fossa navicularis
Four grafts that have been successfully
used
 primary urethral reconstruction
the full-thickness skin graft,
bladder epithelial graft,
oral mucosal graft
○ Buccal,Labial and Lingual, and
rectal mucosal graft.
 Split-thickness skin grafts have been
used for staged anterior urethral
reconstruction
 Flaps
 Tissue transferred with the blood supply intact or
surgically reestablished
A random flap is a flap without a defined cuticular vascular
territory.The flap is carried on the dermal or laminar
plexuses;
○ the dimensions of random flaps can vary widely from individual
to individual and from body site to body site.
axial flap- defined vessel in the base of the flap.
○ three types of axial flaps.
 The direct cuticular axial flap is a flap based on a vessel superficial to the
superficial layer of the deep body wall fascia e.g groin flap
 A musculocutaneous flap (Fig. 40-4A) is based on the vascularity to the
muscle. The overlying skin paddle is carried on perforators.
- If the muscle alone is carried as a flap, the overlying skin survives
as a random unit.
 The fasciocutaneous system of vascularity (Fig. 40-4B) is similar to the
musculocutaneous system.
Classification by elevation technique
 flap also can be classified by the elevation
technique.
A peninsular flap is a flap in which the vascular
continuity and the cutaneous continuity of the flap base
are left intact
An island flap(see Fig. 40-3B) is a flap in which the
vascular continuity is maintained; however, the
cuticular continuity is divided. A true island flap is
elevated on dangling vessels.
 The microvascular free-transfer flap (free flap)(see
Fig.40-3C) has the vascular continuity and the cuticular
continuity interrupted. The vascular continuity is then
reestablished at the recipient site
Generalities of Reconstructive 
Surgical Techniques
 A headlight or suction with attached light often adds
to visualization, especially in deep perineal surgery.
 In penile cases, such as reconstruction of the fossa
navicularis or correction of penile curvature, bipolar
cautery is used exclusively
 In other cases, monopolar cautery can be used
in the superficial structures, but
 bipolar cautery –
○ around the corpus spongiosum,
○ elevation of penile and scrotal flaps,
○ division of the perineal intracorporeal space, and
○ dissection of the dorsal neurovascular structures.
 Appropriate instruments for genitourinary reconstructive
surgery can commonly be found in a plastic surgery tray or
on the peripheral vascular tray in the typical operating
room.
fine tenotomy scissors, fine forceps, various skin hooks, and
delicate needle holders. Sharp scissors that cut with minimal
collateral trauma are essential
Fine suture such as 5-0 and 6-0 chromic or polyglactin can be
used to suture the epithelium to the adventitia of the corpus
spongiosum to control bleeding.
 For a flap or graft repair, 4-0 to 6-0 suture is usually
adequate.
For primary anastomosis of the corpus spongiosum or for a
posterior urethral reconstruction, 3-0 suture may be appropriate
because of tying concerns.
 For penile surgery, a Scott retractor with
stay hooks (Lone Star Medical Products,
Houston, TX,
 the Jordan-Bookwalter perineal retractor set
(C. S. Surgical, Slidell, LA; J. Hugh Knight
Instrument Company, New Orleans, LA),
or
 the Omni-Tract perineal retractor (Omni-
Tract Surgical, Division of Minnesota
Scientific, St. Paul, MN) is helpful.
Penile Urethral stricture Rx
 McAninch
 DISTAL PENILE CIRCULAR FASCIOCUTANEOUS FLAP
 can be used in uncircumcised as well as circumcised men. It yields a hairless flap
of up to 15 cm in length and can be used for strictures from the fossa navicularis to
the bulbar urethra, making it extremely versatile.
 If the penis is uncircumcised, then the inner prepuce is chosen for the flap,
whereas if the penis is circumcised, then the distal penile skin is used.
 Orandi
 LONGITUDINAL VENTRAL PENILE SKIN FLAP WITH A LATERAL PEDICLE
 This technique is appropriate for strictures of the penile urethra only and has
the disadvantage that with proximal extension of the flap one may incorporate hair-
bearing skin
 Turner-Warwick
 LONGITUDINAL VENTRAL PENILE SKIN FLAP WITH A VENTRAL PEDICLE
 bilaterallypedicled island penile skin flap (or BiPIPS), which differentiates it from the unilaterally pedicled
island penile skin flap.
 Barbagli -DORSALLY PLACED BUCCAL MUCOSA GRAFT
 Johannson TWO-STAGE URETHROPLASTY (
BMG
 Humby in 1941London, teated urethral
fistulas after failed hypospadia repair in an 8
yr old child.
 1993 el Kasaby, Egypt first described BMG
for penile and bulbar stricture.
 Morey and Mcaninch -1996- from cheek
mucosa rather than Lip, to avoid deformity
Two teams, special mucosal stretcher
 Standard bulbar urethroplasties should have
a lifetime success rate upto 92%
Buccal mucosa
 has a thick, non-keratinized epithelium that
makes it easy to handle and suture.
 The thin, richly vascularized lamina propria
leads to excellent graft take, and
 Has pan-dermal vascular plexus which is
not interrupted with thinning.
 It is a moist epithelium, and this factor may
have implications for long-term success.
 the donor site morbidity is very acceptable.
Harvesting BMG
 Stensen’s duct is identified opposite the second upper molar and avoided
during the dissection.
 The graft is marked and we infiltrate underneath it with 1/2% lidocaine with
epinephrine to aid hemostasis.
 Silk 3.0 through lip for traction
 The border of the graft is incised, and it is then elevated off of the underlying
muscle with tenotomy scissors.
 Bilateralgrafts may be taken if needed.
 The graftis then thinned and often reconfigured because it is sometimes
necessary to take it in the shape of a rhomboid (wider near the lip and
narrowed in the back of the mouth) to get the necessary length.
 Reconfiguration is done using 5-0 chromic to get a rectangular graft 2.2–2.5
cm in width.
 The graft is placed in saline, excess fat and muscle is removed
 Closure of harvest has been associated with worst pain
 16% and 32% had longterm complaints of numbness and mouth tightness
Pre op evaluation and prep
 Not suitable for
Pts who chew Areca Nut
○ Submucosal fibrosis
Who chew tobacco
Infectious disease affecting the mouth
○ Candida, Lichen, Varicella, Herpes
Pts who had surgery in the mandibular arch
prohibiting wide opening of mouth.
Who play wind instruments or speakers.
Pre op
 Three days prior to surgery ,
chlorhexidine mouthwash twice daily
 Day before surgery, IV antibiotics
instruments
 A Kilner-Doughty mouth retractor
 A 10-ml syringe with 10 ml solution
with bupivacaine HCL 2.5 mg/ml and
epinephrine acid tartrate 0.0091 mg
(0.005 mg epinephrine).
 ◦ Bipolar electrocautery.
 ◦ 5-zero polyglactin sutures (or
similar).
 Nasal intubation is not mandatory but presents
the following advantages:
The nasal tube is smaller and softer than the oro-
tracheal tube and thus more comfortable for the
patient.
• Nasal intubation is more useful in patients with a
small mouth or a limited mouth opening.
• Nasal intubation is more useful at the beginning of
our learning curve.
• Nasal intubation is more useful in patients
requiring double graft harvestings.
 three stay sutures are placed along the edge of the mouth
to stretch the oral mucosa
 If the Stensen duct cannot be clearly identified, applying
some drops of lemon juice to the tongue can stimulate
secretion from the parotid gland.
 For 1-stage urethroplasty the graft is designed in an ovoid
shape, 1.5 cm from the Stensen duct and 1.5 cm from
the external edge of the cheek
 Although the size of the graft varies according to the
cheek size and stricture length, for standard 1-stage penile
or bulbar urethroplasty it should be 4 cm long and 2.5 cm
wide
compln
 Bleeding,pain, facial swelling, stensen’s
duct injury, lip parastesia and restriction
in mouth opening
 Facial swelling and restriction of mouth
opening are common but are self limiting
and will resolve in 3 months.
Post op
 An ice bag is applied to the cheek for 24 h to reduce
pain and the risk of haematoma formation.
 The patient consumes a cold clear liquid diet on the
first postoperative day before advancing to a regular
diet
 The patient continues using a chlorhexidine mouthwash
for oral cleansing twice a day for 3 days after surgery
and is maintained on oral antibiotics until the catheter
is removed.
 Suggest the closure of an ovoidal shaped donor site
and the non-closure of a rectangular shaped donor site
Ventral graft
 the ideal candidate for a ventral buccal
mucosa onlay graft repair is a patient
with a bulbous urethral stricture more
than 3 cm in length and a fairly healthy
corpus spongiosum
 The urethrotomy is continued with
tenotomy scissors proximally through
the stricture and for at least 1 cm into
healthy urethra
 The graft is then sutured to the urethral mucosa
distally and proximally using five to seven
interrupted sutures of 4-0 or 5-0 PDS with the
epithelial surface facing inward toward the lumen
 The lateral closure is then done using running 5-
0 PDS in a watertight fashion
 The corpus spongiosum is then closedover the
top of the graft usingrunning 4-0 PDS
 The urethral catheter is then plugged and taped
to the lower abdomen without tension.
Dorsal Buccal Mucosa Onlay Graft

1. when the corpus spongiosum is not adequate to cover a ventral

graft due to scarring

2. when a stricture extends distally into an area where the corpus

spongiosum is not thick enough to cover a ventral graft,
1. such as the distal bulbous, penoscrotal, or penile urethra

3. Some surgeons primarily use dorsal grafts in all areas for the
theoretical advantage of improving graft take

4. decreasing the incidence of sacculation of the graft

 The corpus spongiosum is mobilized completely off of the underlying corporal

bodies and then rotated180º so that the urethrotomy incision can be made on

the dorsal aspect of the urethra

 The urethrotomy is carried through the stricture and 1 cm into healthy urethra

distally and proximally.

 The graft is then spread and fixed onto the corporal bodies with the epithelial

surface facing inward toward the lumen

 It is sutured in place usinginterrupted 5-0 chromic sutures peripherally, with

additional sutures placed in the central area of the graft as well.

 The proximal and distal ends of the graft are sutured to the edge of the corpus

spongiosum and urethral mucosa using five interrupted sutures of 5-0 PDS

(Fig. 40.7C), with the lateral sutures lines being closed with running 5-0 PDS
Augmented Anastomotic Repair Using
Ventral Buccal Mucosa
 For a lengthy stricture to have an area that is more narrow and dense than
the remainder of the stricture
 excise the dense narrow stricture and to anastomose the urethra ventrally or
dorsally to improve the urethral plate, shorten the length of graft needed, and
optimize graft take
 This excision can be done partial thickness or full thickness
 ventral urethrotomy is made in standard fashion.
 One can then observe the urethral plate to see if there is an area of particular
narrowing or scar that would be amenable to excision.
 If it is 1 cm or less in length and not associated withfull-thickness
spongiofibrosis, the urethral mucosa and the scarred underlying spongiosum
can be excised partial thickness leaving some healthy spongiosum in place.
 The urethral mucosa is sutured together using interrupted sutures of 5-0 PDS
with the knots buried.
 If the narrowed portion is longer or there is full-thickness
spongiofibrosis, the urethral is fully mobilized off of the corporal
bodies from the suspensory ligament distally to the departure of
the urethra from the bulb proximally.
 The stricture is then excised full thickness
 Buck’s fascia is dissected off of the distal urethral segment if
needed to aid extensibility and the intracruralspace can be
developed as well.
 Dorsal wall anastomosis is done using interrupted 4-0 PDS
posteriorly (Fig. 40.8C),initially in one layer and then converting
to a two-layer closure as one proceeds laterallywith4-0 PDS on
the spongiosum and 5-0 PDS on the urethral mucosa.
 The repair proceeds as described for a ventral buccal mucosa
onlay graft
 Augmented Anastomotic Repair Using
Dorsal Buccal Mucosa
 After full mobilization of the bulbous urethra off of the
corporal bodies, the urethra is rotated180º
(Fig.40.9A,B)and a dorsal urethrotomy incision
performed.
 The problematic area is excised as noted above.
 In this setting it is helpfulto spreadfix the graft onto the
corporal bodies before doingthe ventral urethral
anastomosis as there is better exposure to the area
 Once the graft is in place, the urethra is sutured
together ventrally (Fig. 40.9D) and the repair is
completed as described above for a dorsal onlay
procedure (Fig. 40.9E,F).
Staged Buccal Mucosa Graft
Urethroplasty
 Patients who have undergone multiple
previous penile operations for hypospadias
may have recurrent stricture disease and
insufficient penile tissues for a flap procedure
or for one-stage graft reconstruction.
 stricture in the setting of balanitis xerotica
obliterans.
 These strictures are usually very dense and
associated with meatal stenosis and variable
lengths of stricture proximal to the meatus
 In the first stage of the repair, the urethra is
opened ventrally through the skin until healthy
urethra is entered
 Post –Op care
 Kept on IV antibiotics while in hospital
 An antibiotic mouthwash is given four times a day, and patients are
placed on a full liquid diet for a few days.
 Followingan EPA, the patient returns for a voiding cystourethrogram
(VCUG) 10–14 d followingsurgery,and
 after a graft procedure the VCUG is done at approx 3 wk.
 Both catheters are removed if there is no extravasation, and
patients are treated with 5 d of a quinolone.
 A urine culture is done mo later to ensure sterility.
 Flexible cystoscopy is performed at 6 mo and1 yr postoperatively.
 If at 1 yr there is an area that is felt to be at risk for future
narrowing, annual cystoscopy is continued until stability is
documented