Review of Microsurgical Posterior Urethral Reconstruction

ABSTRACT

Posterior urethra reconstruction can be a challenging proposition for both patient and surgeon. The vast majority of urethras can be successfully reconstructed with either anastomosis or grafting. However, there are some patients who have recurrent urethral strictures that require more complex reconstruction. There is some speculation that microsurgical penile revascularization may allow subsequent graft reconstruction with lower stricture rates, but this is not yet proven. For the most tenacious urethral strictures, free tissue transfer may be required. The free radial forearm flap is well suited for urethral reconstruction, and the free anterolateral thigh flap may also have a role for these patients. This article will review urethral trauma and strictures and microsurgery’s role in reconstruction of the posterior urethra.

KEYWORDS

Urethra - revascularization - radial forearm

REFERENCES

• 1 Santucci R A, Joyce G F, Wise M. Male urethral stricture disease.  J Urol. 2007;  177 1667-1674
• 2 Meeks J J, Erickson B A, Granieri M A, Gonzalez C M. Stricture recurrence after urethroplasty: a systematic review.  J Urol. 2009;  182 1266-1270
• 3 Mouraviev V B, Santucci R A. Cadaveric anatomy of pelvic fracture urethral distraction injury: most injuries are distal to the external urinary sphincter.  J Urol. 2005;  173 869-872
• 4 Hosseini J, Tavakkoli Tabassi K. Surgical repair of posterior urethral defects: review of literature and presentation of experiences.  Urol J. 2008;  5 215-222
• 5 Xu Y M, Qiao Y, Sa Y L et al.. Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection.  Eur Urol. 2007;  51 1093-1098 discussion 1098-1099
• 6 Barbagli G, Lazzeri M. Urethral reconstruction.  Curr Opin Urol. 2006;  16 391-395
• 7 Andrich D E, Mundy A R. What is the best technique for urethroplasty?.  Eur Urol. 2008;  54 1031-1041
• 8 Koraitim M M. On the art of anastomotic posterior urethroplasty: a 27-year experience.  J Urol. 2005;  173 135-139
• 9 Cooperberg M R, McAninch J W, Alsikafi N F, Elliott S P. Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25-year experience.  J Urol. 2007;  178 2006-2010
• 10 Wadhwa S N, Chahal R, Hemal A K, Gupta N P, Dogra P N, Seth A. Management of obliterative posttraumatic posterior urethral strictures after failed initial urethroplasty.  J Urol. 1998;  159 1898-1902
• 11 Ecke T H, Hallmann S, Gerullis H, Ruttloff J. Reconstruction of the urethra with a Surgisis onlay patch in urethral reconstructive surgery: two case reports.  J Med Case Reports. 2009;  3 6542
• 12 Wessells H, McAninch J W. Current controversies in anterior urethral stricture repair: free-graft versus pedicled skin-flap reconstruction.  World J Urol. 1998;  16 175-180
• 13 Dabernig J, Shelley O P, Cuccia G, Schaff J. Urethral reconstruction using the radial forearm free flap: experience in oncologic cases and gender reassignment.  Eur Urol. 2007;  52 547-553
• 14 Munarriz R M, Yan Q R, ZNehra A, Udelson D, Goldstein I. Blunt trauma: the pathophysiology of hemodynamic injury leading to erectile dysfunction.  J Urol. 1995;  153 1831-1840
• 15 Babaei A R, Safarinejad M R, Kolahi A A. Penile revascularization for erectile dysfunction: a systematic review and meta-analysis of effectiveness and complications.  Urol J. 2009;  6 1-7
• 16 Shenfeld O Z, Kiselgorf D, Gofrit O N et al.. The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption.  J Urol. 2003;  169 2173-2176
• 17 Rashid M, Sarwar S U. Avulsion injuries of the male external genitalia: classification and reconstruction with the customised radial forearm free flap.  Br J Plast Surg. 2005;  58 585-592
• 18 Garaffa G, Raheem A A, Christopher N A, Ralph D J. Total phallic reconstruction after penile amputation for carcinoma.  BJU Int. 2009;  104 852-856
• 19 Harrison D H. Reconstruction of the urethra for hypospadiac cripples by microvascular free flap transfers.  Br J Plast Surg. 1986;  39 408-413
• 20 Kanno T, Shibasaki N, Ito M et al.. Infection-induced urethral defect treated by urethral reconstruction with a radial forearm flap.  Int J Urol. 2005;  12 228-230
• 21 Cheng K X, Hwang W Y, Eid A E, Wang S L, Chang T S, Fu K D. Analysis of 136 cases of reconstructed penis using various methods.  Plast Reconstr Surg. 1995;  95 1070-1080 discussion 1081-1084
• 22 Morrison W A, Webster H R, Kumta S. Urethral reconstruction using the radial artery forearm free flap: conventional and prefabricated.  Plast Reconstr Surg. 1996;  97 413-419
• 23 Erickson B A, Dumanian G A, Sisco M, Jang T L, Halverson A L, Gonzalez C M. Rectourethral fistula associated with two short segment urethral strictures in the anterior and posterior urethra: single-stage reconstruction using buccal mucosa and a radial forearm fasciocutaneous free flap.  Urology. 2006;  67 195-198
• 24 Ozkan O, Ozkan O. The prefabricated pedicled anterolateral thigh flap for reconstruction of a full-thickness defect of the urethra.  J Plast Reconstr Aesthet Surg. 2009;  62 380-384
• 25 el-Kassaby A, AbouShwareb T, Atala A. Randomized comparative study between buccal mucosal and acellular bladder matrix grafts in complex anterior urethral strictures.  J Urol. 2008;  179 1432-1436
• 26 Aboushwareb T, Atala A. Stem cells in urology.  Nat Clin Pract Urol. 2008;  5 621-631
• 27 Tonkin J B, Davies T O, Colen L B et al.. Preoperative vascular considerations in patients undergoing free flap genital reconstruction after infectious loss of genital tissue.  J Urol. 2009;  181 (4S) 424