Dvog Proximal Bulbar Urethroplasty

configuration of the meatus is often lost with the dorsal Y-V flap procedure.

17.2.1 Isolated Stricture of the Fossa

Navicularis Following Transurethral Resection of the Prostate

Patients who present with an isolated meatal fossa stricture following transurethral resection of the prostate generally gain little from repetitive dilations; however, reliable reconstruction of the meatus and fossa navicularis with nearly perfect functional and cosmetic results can be accomplished using several surgical techniques.

17.2.1.1 Y-V flap Procedures

Flap procedures for repair of true fossa navicularis strictures founded on the Y-V principle were described by Cohney [1] and Blandy [2]. Cohney's procedure uses a ventral transverse peninsula flap, usually with random vascularity. The flap is transposed and interdigitated into the meatotomy, creating a retrusive meatus with a »dog ear« at the transposition site (O Fig. 17.3B). Blandy's modification creates a vertical skin peninsula flap on the midline of the penile shaft that is usually elevated with random vascularity and advanced into the meatotomy (O Fig. 17.3A). Although elevation with the fascial blood supply intact and elimination the »dog ear« are theoretic improvements over the Cohney procedure, the Blandy modification still leaves the patient with a coronal or distal shaft meatus. The functional results of both of these techniques are adequate when stenosis is confined to the fossa navicularis; however, both have been criticized due to their suboptimal cosmetic results.

A modification of Blandy's procedure has been described by Brannen [3]. This procedure involves elevation of a peninsula flap based on the dartos fascial blood supply with aggressive advancement into the meatotomy defect (O Fig. 17.3C). Although the design of the longer flap was intended to place the meatus closer to the tip of the glans, most patients are left with a retrusive meatus and the unsightly appearance of shaft skin advanced into the ventral glans. Thus, in most cases, this modification yields neither a functional nor cosmetic improvement over Cohney's or Blandy's original flap designs.

Brannen's procedure was then modified by DeSy, who used a longitudinal skin island mobilized on the dartos fascia and aggressively advanced it into the meatotomy defect by inverting the skin island (O Fig. 17.3D). Mobilized on a dartos fascial pedicle with the ventral glans fused ventrally over the dartos fascial strip, this procedure also requires a lengthy advancement of the midline dartos fascia. However, DeSy has reported excellent functional and cosmetic results [4].

17.2.2.2 Resurfacing of Fossa Navicularis

Devine reported a procedure he termed resurfacing the fossa navicularis, applicable to only short strictures confined to the intraglanular urethra [5]. This procedure involves excision of the strictured area with placement of a penile skin graft (O Fig. 17.3E). As an alternative, a tubed buccal mucosa graft could be used in lieu of a skin graft.

17.2.2.3 Transverse Ventral Penile Skin Island

One of the authors of this chapter (GHJ) has described a procedure for reconstruction of the meatus and fossa navicularis that was intended primarily for strictures confined to the fossa navicularis [6], but can be used for structures up to 4.5 cm in length. Initially, a wide urethrostomy is created through the stenotic meatus and fossa down to the level of the normal urethra. The technique then involves elevation of a transverse ventral penile skin island on a broad ventral dartos fascial pedicle. The skin island is transposed and inverted into the meatotomy defect. Although the broad dartos pedicle allows vigorous mobilization of the ventral fascial pedicle, it requires more aggressive dissection of the lateral glans flaps to assure a tension-free ventral glans fusion. The surgical technique for this procedure is described in detail below.

Evaluation with retrograde and voiding contrast medium and urethroscopy is performed in all surgical candidates. Urethroscopy is usually performed with a small, rigid pediatric cystopanendoscope. For patients in whom this is not possible but in whom contrast studies have indicated that the stenotic process is confined to the fossa, endosco-py is performed through the area of stenosis immediately after the urethrotomy is complete, to assure the surgeon that the stricture does not extend into the more proximal urethra.

The surgical approach is generally through the patient's existing circumcision incision; in patients who have not been circumcised, it is via a partially circumcising incision on the ventral surface of the penis. The ventral penile skin and dartos fascia are elevated in the plane immediately superficial to the superficial lamina of Buck's fascia and, in some cases, the ventral aspect of Buck's fascia can be mobilized and included as the flap's deep layer. A grooved director is passed through the stricture and an external urethrotomy is made through the stricture in the fossa and extended approximately 1-1.5 cm into the normal urethra (O Fig. 17.4).

The normal urethra is identified by bougienage and endoscopy. The dimensions of the remaining glanular epithelial strip are measured and a transverse skin island is outlined on the ventral penile skin and tailored to produce a 28- to 30-Fr neofossa navicularis. The island is elevated to preserve the dartos fascial pedicle by incising

Bulbar FossaMeatotomy RepairBulbar FossaFossa Navicularis Urethral Stricture

O Fig. 17.3A-E. Techniques for correction of strictures of the urethral meatus and fossa navicularis. A Technique as described by Blandy. This utilizes a mid-line skin peninsula flap advanced into a meatotomy defect but creates a retrusive meatus. B Cohney's technique (creation of a ventral transverse skin flap). C Brannen's modification utilizing a more aggressive advancement of a mid line dartos-based peninsula flap. Note that penile skin is advanced onto the ventral glans. D DeSy's technique. A longitudinal skin island is mobilized on dartos fascia, aggressively advanced, and inverted into a meatotomy. The ventral glans is then fused over the repair. E Resurfacing of the fossa navicularis as described by Devine. (From[101)

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