F. Schreiter, B. Schönberger*
Introduction - 162
Introduction - 162
20.2 Patient Preparation for Surgery - 162
20.3 Instruments - 162
20.4 Surgical Procedures According to the Type of Stricture - Step by Step - 163
20.4.1 One-Stage Meatoplasty - 163 22.214.171.124 Buccal Mucosa or Foreskin Graft Urethroplasty - 163
20.4.2 Pedicled Flap Urethroplasty (Jordan) -164
20.4.3 Pedicled Penile Flap Urethroplasty (Quartey-Orandi-Devine) - 164
126.96.36.199 The Quartey Technique - 164
188.8.131.52 The Orandi-Devine technique - 164
20.4.4 Dorsal Buccal Mucosa Graft (Barbagli) -164
20.4.5 Two-Stage Buccal Mucosa Graft (Brakka) - 170
20.4.6 Dorsal Onlay Graft Urethroplasty (Barbagli) - 171
20.4.7 Dorsal Augmented Anastomotic Urethroplasty - 172
20.5 Tips and Tricks - 173
20.6 Possible Complications - 173
20.7 Remarks - 173 References - 173
r Professor Schönberger has died since this chapter was completed.
Anterior urethral strictures may involve the Fossa navicu-laris, the pars pendulans of the urethra, and part of the bulbar urethra. This strictures can be caused by inflammatory disease, including lichen sclerosis or balanitis xerotica obliterans (BXO) of the corpus spongiosum (1), traumatic scarring after a blunt trauma or traumatic catheterization, long-term indwelling catheter treatment, and forced bougienage, as well as congenital anomalies (hypospadias, epispadias), and hypospadias resulting from multiple previous reconstructions. The use of scrotal or genital skin can lead to hair-growing, inflammation, stone formations, and diverticula.
Since the use of buccal mucosa  was included in urethral stricture repair, the tendency has clearly gone from pedicle flap procedures [4-7] to a one-stage free graft repair.
Free preputial grafts of the inner sheet of the foreskin
- a moist full-thickness skin graft lacking of hair follicles
- seems to provide similar good long-term results.  The easy handling of the harvesting and transfer of the grafts that are free of hair may be the greatest advantage.
Hypospadia patients (O Fig. 20.1A, B) or patients who have undergone multiple previous procedures of ure-
thral reconstruction develop severe scarring and present an operative challenge. The problems develop from the absence of healthy tissue that can be used for urethral reconstruction. In those cases, a two-stage procedure is recommended, which can either be performed by using buccal mucosa in a two-stage procedure  or using a free split skin graft, the so-called two-stage mesh graft procedure .
The day before surgery, a complete bowel preparation should be performed. A special liquid diet is favorable. On the day of surgery, the genital area and the perineum are shaved.
Fine surgical instruments are used as well as magnifying glasses 1:2.5-3.5; dilatation set up to 30 Fr; Bipolar electrocoagulation; submucosal injection (adrenaline 1:100,000); Scott retractor; cystoscope; suture material 4-0 to 6-0 absorbable; and nonadhesive wound dressing.
20.4 Surgical Procedures According to the Type of Stricture - Step by Step
20.4.1 One-Stage Meatoplasty
184.108.40.206 Buccal Mucosa or Foreskin Graft Urethroplasty
Indications include short meatal stricture within the glans penis or hypospadia meatal stenosis.
™ A buccal mucosa graft (if available) is harvested from the lower lip or the cheek. If foreskin is available it can be harvested from the inner sheet as well (□ Fig. 20.2C).
™ The graft is sutured to the left rim of the opened navicular fossa.
™ The graft is rotated over the urethral plate and sutured to the right rim of the glandular urethra with the mucosal or epithelial surface looking to the urethra (□ Fig. 20.2D).
™ The glans is closed over the graft and a 20-Fr catheter or silicon stent is left in place for 10 days (Fig. 20.2e).
20.4.2 Pedicled Flap Urethroplasty (Jordan)
The flip-flap technique (Jordan flap) gives excellent cosmetic and functional results. This technique is used for meatal strictures extending beyond the glans penis (O Fig. 20.3).
™ The flap is prepared crosswise on the ventral side of the distal penile shaft (O Fig. 20.3A). ™ Open the stricture until healthy tissue of the corpus spongiosum is reached (O Fig. 20.3B). ™ The pedicle has to be prepared as long as the flap can be rotated 90 degrees (O Fig. 20.3C). ™ The rotated flap is sutured to rim of the urethral plate (O Fig. 20.3D).
™ The penile shaft skin is sutured over the Jordan flap using a asymmetric penile skin flap (Bayars) (O Fig. 20.3E).
™ Or, if possible, the edges of the glans are sutured over the Jordan flap (O Fig. 20.3F).
20.4.3 Pedicled Penile Flap Urethroplasty (Quartey-Orandi-Devine)
This technique is recommended in patients with extended penile strictures with or without stricture of the fossa navicularis. Enough penile skin has to be available. This technique is especially used for patients who wish to avoid harvesting of buccal mucosa and in circumcised patients. A transverse penile skin flap can be prepared with a long vascularized pedicle that can be rotated 90 degrees and can also be pulled through underneath the scrotum to reach the bulbar urethra (Quarty-technique). A longitudinal penile flap (Orandi-Devine) is easy to prepare with a short pedicle that allows the flap to be rotated with its epithelial surface to the marsupialized urethral plate.
220.127.116.11 The Quartey Technique
™ Midline incision in the raphe of the penis and deglo-
ving the penile skin. (O Fig. 20.4A). ™ Transverse dissection of the penile flap (O Fig. 20.4B). ™ Careful dissection of the tunica dartos pedicle between the two layers of penile skin vessels (O Fig. 20.4C). ™ Splitting of the strictured urethra (O Fig. 20.4D). ™ Trimming of the flap to the length of the stricture and suturing first to the left rim of the stricture and thereafter to the right side of the stricture over a 20-Fr indwelling catheter (O Fig. 20.4E). ™ Covering of all suture lines with the tissue of the tunica dartos (O Fig. 4F). ™ The penis is covered with the outer penile skin (O Fig. 20.4G).
™ For repair of bulbar strictures, the long pedicled flap is pulled through the under side of the scrotum (O Fig. 20.5A, B)
™ The flap is sutured to both rims of the opened urethral stricture using a running 5-0 resorbable suture material (O Fig. 20.5C).
™ The tissue of the pedicle (tunica dartos) is used to cover the sutures of the flap to prevent fistulae (O Fig. 20.5D).
™ Covering the bulbocavernosus muscle and closure of the wound (O Fig. 20.5E).
™ Peritomy of the flap in the middle of the penile shaft. For long strictures the flap can be lengthened by cutting the flap further on subcoronarially. (O Fig. 20.6A).
™ A short pedicle is prepared so that the rotation of the flap is without tension (O Fig. 20.6B).
™ The flap is rotated and sutured to the rim of the strictured urethra on both sides (O Fig. 20.6C, D).
™ The tunica dartos is sutured over the flap to cover all suture lines and prevent fistulae (O Fig. 20.6D).
™ The skin is covered over the flap. Sometimes a rotated Byars flap is necessary to reconstruct the skin (O Fig. 20.6E).
20.4.4 Dorsal Buccal Mucosa Graft (Barbagli)
This technique is suggested for repairing of penile urethral strictures only in patients with normal corpus spongiosum of the urethra In anterior strictures, it is seldom used)
™ Total stripping of the penile skin including the tunica dartos (□ Fig. 20.7A). ™ Ventral opening of the corpus spongiosum to the healthy tissue. Incision of the urethral plate in the midline dorsally and mobilization of the lateral wings of the urethral plate (□ Fig. 20.7B). ™ The gap of the urethral plate is covered using a buccal mucosa or free preputial graft using 6-0 interrupted resorbable sutures. (□ Fig. 20.7C). ™ Over a 20-Fr catheter, the corpus spongiosus is sutured (□ Fig. 20.7D). ™ The glans and the penile skin are closed covering the urethra with the dartos tissue underlying the penile skin. (□ Fig. 20.7E).
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