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Transmeatal Endoscopic Management of Anterior Urethral Strictures: Thinking Outside the Box

By: Hayley A. Premo, MD, Mayo Clinic, Rochester, Minnesota; Yeonsoo Sara Lee, MD, Mayo Clinic, Jacksonville, Florida; Jonathan N. Warner, MD, Mayo Clinic, Rochester, Minnesota | Posted on: 30 Dec 2024

The buccal graft urethroplasty, first introduced by Kirill Sapezhko in the early 19th century,1 has led to remarkable improvements in urethral reconstructive surgery. The popularization of buccal graft urethroplasty by Morey and McAninch2 led to innovations in urethral stricture care, including the evolution of 1-stage vs multistaged procedures, the development of nontransecting approaches, and the successful application of buccal grafts to radiated tissue. The next frontier is to make these surgical advancements less invasive. Despite being pioneered more than 45 years ago, there has been limited progress in the refinement or adoption of transmeatal endoscopic surgery.

Endoscopic urethroplasty was first introduced by Pettersson et al in 1977. The technique involved harvesting a split-thickness skin graft from the thigh and adhering the graft to a 20F Foley catheter following dorsal direct visual internal urethrotomy.3 Despite promising results and low patient morbidity,4,5 there has been minimal progress in refining and standardizing the technique, especially when compared to the significant strides made in open urethroplasty. In this article, we will detail our specific endoscopic techniques and present the initial outcomes.

For any stricture, the first step is to create a urethrotomy. A cold knife is used to make a single incision along the ventral aspect of the stricture to achieve a urethral caliber of 30F. In cases of severe stenosis, we incise into the underlying dartos fascia or fat. As opposed to a dorsal incision, which relies on vascular support from the corporal body alone, a ventral incision draws support from the underlying spongiosum, dartos fascia, or periurethral tissue. At the very least, a ventral incision maintains options for dorsal preservation should the patient require subsequent open revision for stricture recurrence. The remainder of our surgical approach is determined by stricture location.

For distal penile urethral strictures, 26F Wolf offset nephroscope is used to pass a rigid 18-gauge endoscopic cystoscopy needle from the urethral lumen through the proximal urethrotomy site under direct vision and then out of the ventral skin (Figure 1, A). A 3-0 PDS suture is then passed down the needle. With the first suture in place, the needle is removed and passed a second time in a nearby location (Figure 1, B). The needle and scope are withdrawn, leaving 2 suture tails exiting the meatus. These sutures are then passed through an appropriately sized buccal graft using a free needle and tied together with the knot on the mucosa side of the proximal graft (Figure 1, C, D). The graft is parachuted into position over the urethrotomy. To secure the graft, proximal 3-0 PDS sutures are placed at 1 cm intervals in a similar fashion using the offset scope (Figure 1, E). Distally, a pair of ski needles can be passed through the meatus as described by Nikolovsky with the modification that we prefer chromic sutures to allow for rapid absorption for improved patient comfort (Figure 1, F, G).6

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Figure 1. Repair of distal urethral stricture. A, Placement of cystoscopic needle via offset nephoscope through urethrotomy. B, 3-0 PDS suture is passed in close proximity via cystoscopic needle. C and D, PDS suture is passed through the proximal end of the graft, and a knot is tied on the mucosal side. E, Graft securement. F and G, Ski needle placed distally through the meatus and used to quilt the graft from distal to proximal. Illustrations used with permission of Yeonsoo S. Lee.

For proximal urethral strictures, we again use the nephroscope and a rigid endoscopic cystoscopy needle to facilitate graft deployment. At the distal aspect of the urethrotomy, the cystoscopic needle is passed through the urethra and out of the perineum (Figure 2, A, B).  A pair of the sutures is then placed on both sides of the urethrotomy.  These are secured externally at the meatus, and careful attention is paid to avoid twisting. The graft is then oriented with the antimucosa facing downward toward the exposed spongiosum and the mucosa facing toward the lumen (Figure 2, C). The previously placed transmeatal suture tails are then passed through the graft from antimucosa to mucosa using a free needle at what will be the distal aspect of the graft.  The suture pairs are tied together, creating a knot on the mucosal side (Figure 2, D). The external sutures are pulled, and the graft retracts into the urethra.  Cystoscopy is performed to flip the graft within the urethra to ensure it is covering the urethrotomy entirely (Figure 2, E). To accomplish graft fixation, the JNW Urtract (LSI Solutions, Victor, New York) device is introduced with the Securestrap (Ethicon, Somerville, New Jersey), which deploys absorbable vicryl tacks. While a finger externally compresses the perineum toward the tip of the Securestrap, the ventral midline portion of the graft is secured (Figure 2, F).

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Figure 2. Repair of proximal anterior urethral stricture. A and B, Using the offset nephroscope, the cystoscopic needle is passed through the urethrotomy and out of the perineum. C, The graft is oriented with the anti-mucosa facing downward toward the exposed spongiosum. D, Suture pairs are tied, creating 2 knots on the mucosal side of the graft. E, Cystoscopy is used to ensure the graft is covering the entire urethral defect. F, The graft is secured with vicryl tacks. Illustrations used with permission of Yeonsoo S. Lee.

For short urethral strictures, defined as < 2 cm, no graft is utilized. Once ventral urethrotomy is performed, the RD180 (LSI Solutions, Victor, New York) laparoscopic suturing device is used to place 2 sutures on either side of the urethrotomy incision site (Figure 3, C). This allows the proximal and distal ends of the mucosa to be secured perpendicular to the urethrotomy in a Heineke-Mikulicz fashion. The Ti-knot (LSI solutions, Victor, New York) device is used to deploy a titanium knot endoscopically, thus anchoring each suture into place (Figure 3, D).

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Figure 3. Repair of short stricture. A, Stricture prior to treatment. B, Incision of stricture. C, Mucosal realignment using RD180® laparoscopic suturing device. D, A titanium knot is endoscopically placed via Ti-knot® device to anchor the suture into place.

Defining success as urethral patency on flexible cystoscopy using a 17F scope at 4 months post-op, short-term patient outcomes have thus far been promising. To date, 35 patients have been endoscopically treated for anterior strictures. With a median follow-up of 9 months (range 4 to 21), 3 patients have experienced stricture recurrence.

The application of minimally invasive surgical techniques to improve patient outcomes while minimizing morbidity is a point of pride within the urologic community. Developing and refining innovative surgical approaches to treat common problems is an important aspect of providing continuous improvements to patient care. The use of transmeatal endoscopic urethroplasty is a safe and promising option for the treatment of anterior urethral stricture disease.

  1. Naude JH. Endoscopic skin-graft urethroplasty. World J Urol. 1998;16(3):171-174. doi:10.1007/s003450050047
  2. Barbagli G, Balò S, Montorsi F, Sansalone S, Lazzeri M. History and evolution of the use of oral mucosa for urethral reconstruction. Asian J Urol. 2017;4(2):96-101. doi:10.1016/j.ajur.2016.05.006. Epub 2016 Jun 26.
  3. Morey AF, McAninch JW. Technique of harvesting buccal mucosa for urethral reconstruction. J Urol. 1996;155(5):1696-1697. doi:10.1016/S0022-5347(01)66167-6
  4. Pettersson S, Asklin B, Bratt CC. Endourethral urethroplasty: a simple method for treatment of urethral strictures by internal urethrotomy and primary split skin grafting. Br J Urol. 1978;50(4):257-261. doi:10.1111/j.1464-410X.1978.tb02821.x
  5. Chiou RK. Endourethroplasty in the management of complicated posterior urethral strictures. J Urol. 1988;140(3):607-610. doi:10.1016/S0022-5347(17)41735-6
  6. Nikolavsky D, Abouelleil M, Daneshvar M. Transurethral ventral buccal mucosa graft inlay urethroplasty for reconstruction of fossa navicularis and distal urethral strictures: surgical technique and preliminary results. Int Urol Nephrol. 2016;48(11):1823-1829. doi:10.1007/s11255-016-1381-1

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