Endoscopic Urethroplasty

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In endoscopic urethroplasty, a free skin transplant is placed in position with the aid of a cystoscope above a urethral stricture, which had been previously incised by means of urethrotomy interna [24-26, 41, 75, 76, 91, 98, 129]. The indication for this technique is the complex, recurrent urethral stricture that could not be treated successfully by urethrotomy. The theory of this method is the epithelialization of the urethra with an available skin graft. The availability of healthy epithelial tissue should reduce the forming of scars and the relapse frequency.

The method requires first that the urethral stricture be incised at the 12 o'clock position. Additionally, a resection of the scar tissue may be necessary in order to create a healthy bed for the skin transplant [42]. After measuring the length of the stricture with the cystosco-pe, a free skin transplant is taken from the forearm or prepuce. The graft should have a thickness of 0.45 cm, the length of the graft should be 2 cm longer than the length measured to allow for sufficient coverage [75]. The width of the graft should be 20 mm and its circumference should correspond to a 20-charr silastic catheter. The overlapping ends become necrotic and will drop off postoperatively.

The next step is to measure the distance between the bladder neck and the proximal end of the urethral stricture with the aid of a measuring balloon. This distance is then marked on a Foley catheter. Then the skin transplant is fixed to the catheter with 4.0-cat-chromic sutures over the measured spots. The epithelialized surface should be facing the catheter. After that the catheter with the graft is pushed forward into the bladder, the balloon is inflated and pulled back to the bladder neck. Then a pressure pack is applied to the penis shaft, in order to fix the transplant in the area of the incised stricture. By means of a suprapubic urine drainage, the bladder should be drained to minimize a flow of urine along the catheter and the thereby resulting damage for the transplant. The patients should be ordered to strict bed rest for a period of 6 days. The urethral catheter will be removed after 10 days and the suprapubic urine drainage 4-6 weeks later.

An alternative method for fixing the transplant is described by Naude [75]. Under endoscope guidance, two thin hollow needles are pushed across the perineum into the urethra - one at the proximal, and one at the distal end of the incised stricture. Nonresorbable sutures are pushed forward from outside into the urethra through the hollow needles and are pulled out through the meatus with the cystoscope. The free transplant is fixed circularly via a balloon dilatation catheter, and both the sutures coming out of the meatus are fixed to each particular end of the graft, and are then pulled back by means of a needle. Then the catheter with the graft is placed above the urethral stricture by pulling at the proximal and in addition at the perineal sutures. The nonresorbable sutures are then fixed across a foam cushion to the perineum. The dilatation balloon is expanded with sodium chloride, in order to fix the transplant to the urethra. A week after the operation, the external sutures are pulled, the balloon unblocked and removed.

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