Authored by Mukesh Chandra Arya*
Abstract
Introduction: Anastomotic urethroplasty in traumatic bulbar stricture is successful in 90-95% of cases, but for post-void dribble and ejaculatory dysfunction (EjD). Here, we present modified muscle and nerve-sparing urethroplasty to overcome these problems.
Material and Methodology: A retrospective analysis (from January 2015- January 2019) of 55 patients with traumatic bulbar stricture managed by standard urethroplasty (Group 1, N=30) and modified urethroplasty (Group2, N=25) was done. The comparison also included their post-operative EjD and post-void dribble.
Results: Mean age of patients was 31.12 (15-55) years. Mean length of stricture was 1.41 [1-2] cm. Mean Qmax was 27.8 and 26.4ml/s in the modified and standard urethroplasty group (P-value>0.05). EjD was calculated for each patient using questions from male sexual health questionnaire (MSHQ)and MSHQ mean scores pertaining to ejaculation had a significant difference between Group1 and Group2 with mean postoperative scores of 14.17 and 21.12 respectively (p-value- <0.005) At 1-year, ten patients (33%) from Group 1 while one patient (4%) in the Group 2 showed post-void dribbling respectively (P-value-0.007).
Discussion: Success rate (patient not needing post-operative intervention) was 100% in modified and 96.66% in standard urethroplasty group. Results in terms of EjD and post-void dribble were statistically significant.
Conclusion: In traumatic bulbar stricture, muscle and nerve-sparing urethroplasty is associated with statistically significant better outcomes in terms of EjD and post-void dribble.
Keywords: Muscle-sparing urethroplasty; End to end urethroplasty; EPA; Traumatic bulbar stricture; Stricture urethra
Abbreviations: EjD: Ejaculatory dysfunction; Qmax: maximum urine flow rate; MSHQ: male sexual health questionnaire; Qmax: Maximum Urine Flow Rate; RGU: Retrograde Urethrogram; SPC: Suprapubic Cystostomy; MCU: Micturating Cystourethrogram; PGA: polyglycolic Acid; DVIU: Direct Visual Internal Urethrotomy
Introduction
Bulbar urethra is the most common site of the stricture (46.9%). Meta-analysis of anterior urethral strictures showed etiology as iatrogenic (33%), idiopathic (33%) and, to a lesser extent, trauma (19%) and inflammation (15%). End-to-end anastomosis is the most valid treatment of choice for short bulbar traumatic urethral strictures, with cure rates close to 100% [1,2]. Bulbospongiosus muscle which covers bulbar urethra is primarily responsible for last few drops of urine and semen expulsion. Ejaculatory dysfunction (EjD) and post-void dribbling are common postoperative complications after muscle cutting bulbar urethroplasty in 23.3% and 29% patients, respectively. Here, we used a modified technique of sparing muscle and nerve to avoid these sequelae.
Material and Methodology
A retrospective analysis of 55 patients (January 2015 to January 2019) with traumatic bulbar stricture was done. Patients with post-inflammatory or with prior catheterization (without trauma) were excluded from the study group. In our department, retrograde urethrogram (RGU) is not done at the time of trauma. Based on the history of perineal trauma with blood at meatus, a presumptive diagnosis of bulbar urethral injury was made and trocar Suprapubic Cystostomy (SPC) was done. RGU and micturating cystourethrogram (MCU)were done at 3 months after injury. In cases with normal urethrogram, the trauma was presumed to be contusion. Such patients who voided well after clamping SPC were excluded. Those who had complete or near obliterative stricture were taken up for this study. Patients were asked about their complaints of post-operative EjD during their follow-up using 5 questions from MSHI (Male Sexual health questionnaire score) pertaining to ejaculation including frequency, volume, force and bother and compared with their pre-operative scores. Also, patients were asked “If they wet their undergarments after passing urine” to ascertain post-void dribble. Statistical analysis between these groups was done using IBM SPSS 25.0. From January 2015 to February 2017, all 30 patients were operated by standard muscle cutting technique (Group 1) and later on, 25 patients by modified muscle and nerve-sparing technique (Group 2). Surgical technique: Detailed history, blood investigations including complete blood count, serum creatinine and ultrasound abdomen was followed by RGU and MCU. Under anesthesia, antegrade and retrograde urethroscopy showed complete cut off at the level of the bulbar urethra. With the patient in the lithotomy position, midline perineal incision was given.
Standard technique: Bulbospongiosus muscle was divided in the midline. The bulbar urethra was mobilized up to the penoscrotal junction. Stricturous segment was identified and excised. A few interrupted 4/0 chromic catgut sutures were taken radially to tack the mucosa to the urethral wall and prevent retraction during the anastomosis. Proximal and distal urethral segment were spatulated at 6’o clock and 12’o clock respectively. End to end anastomosis was done over 14 Fr Silastic Foleys catheter using 4-0 polyglycolic acid(PGA) and drain was put before layered closure. The drain was removed on post-operative day 2 and Foleys catheter on day 21.
Modified technique: The perineal branch of the pudendal nerve is damaged during dissection of bulbospongiosus muscle which cannot be restored by suturing the muscle. So bulbospongiosus muscle was carefully separated from the corpus spongiosum by sharp dissection leaving the lateral margins of the muscle and central tendon of perineum intact. To expose the bulbar urethra, the muscle was pulled down using two small right-angle retractors (Figure 1).
The scarred urethra was excised and both ends were spatulated as in the standard technique. The proximal urethral segment was sutured to corpora at 11,12 and 1’O clock, followed by an end to end anastomosis. Ventrally thick corpus spongiosum was sutured in two layers from 3 – 9 o’clock with continuous 4-0 PGA suture over 14 F Silastic Foleys catheter (Figure 2).
This establishes early vascular continuity in corpus spongiosum and achieves better healing. The closure was done as in the standard technique. Prophylactic 3rd generation cephalosporin and amikacin were given for 3 days. Postoperative uroflowmetry was done at 6 weeks and RGU was done at 6 months (for documentation) in all patients. Patients were followed up for a period of one-year and were asked about their EjD and post-void dribble. Failure was considered if the patient had symptoms post-operatively or required an ancillary procedure. The patient was considered cured in the absence of symptoms and not needed any intervention.
Presentation: One patient (Group 1) presented with periurethral abscess following catheterization after trauma. SPC and drainage of the abscess was done. Rest of the patients were managed with immediate SPC followed by MCU and repair at three months.
Duration: The mean duration of surgery was 65 (54-74) minutes in Group 1 and 70 (58- 84) minutes in Group 2.
Length of stricture: Mean length of the stricture was 1.41 cm in our series. Length of the stricture was 1.47 and 1.36cm in Group 1 and 2 respectively.
Postoperative uroflow: Uroflow was done at 6 weeks and overall Mean Qmax was 23.036 ml/s (Table 2).
Results: Success rate (patient not needing post-operative intervention) was 100% in modified and 96.66% in standard urethroplasty group.
Post-operative EjD: EjD was evaluated by asking patients questions about frequency, volume, force and bother related to their ejaculation. Questions were framed from MSHQ (MSHQ5, MSHQ7, MSHQ8, MSHQ9, MSHQ12). Group 1 and Group 2 patients had a significant difference in their score pertaining to EjD and P-value was highly significant (Table 3, Figure 3).
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