Urethral reconstruction is the creative
application of tissue transfer principles, and it is
more an art than a science. In this page 4 important
questions to urethral reconstruction.
Surgical experience, procedure selection,
operative technique, stricture location and nature of
the disease all influence outcome. A multivariate analysis
showed that longer strictures were more likely to fail
long term, even when the same method of repair was used
in various locations. It may be that longer strictures
simply "outgrow" the repair over time in some
cases, especially those originating from chronic inflammatory
conditions such as lichen sclerosus.
How do the frequency and timing of
urethral dilations influence stricture length and
urethral reconstruction results?
Andrich et al suggest that repeated dilation tends
to exacerbate simple strictures.They note an increasing
trend toward immediate urethral reconstruction, which
appears to have yielded procedure simplification and
improved outcomes during the last decade. We have
observed that most strictures not previously subjected
to repeated instrumentation are amenable to an anastomic
procedure, while those that have been frequently manipulated
often require tissue transfer. Another underappreciated
point is that many experts advise at least a 3-month
period of "urethral rest" to enable clear
distinction between normal and scarred tissue at the
time of urethral reconstruction.
How does the surgeon decide which
procedure to perform in the urethral reconstruction
are difficult to measure precisely in length and severity.
The London group reports excellent results when short
strictures are treated by an anastomotic procedure
but they do not prescribe specific guidelines for
procedure selection. Ultrasound, while helpful in
select cases, has not been widely used due to time
and cost constraints.
What do the patients think about various procedures
of "urethral reconstruction"?
With an increasing trend toward performing single stag urethroplasty as an outpatient procedure, multistage procedures should
be reserved for a selvage setting, as in reoparative hypospadias cases and those with extremely advanced stricture diseases. The most
sexually active patients prefer single stafe for urethral reconstruction