Abstract
Urethral stricture disease is the commonest cause of morbidity in urology practice in sub-Saharan Africa. In contrast, prostate disease is commonly cited as the leading cause of urological disease in most urology practices in developed countries. In Africa, the aetiology of urethral stricture disease is compounded by a high prevalence of sexually transmitted infections (STIs), increasing levels of urethral trauma and over-stretched urological services. Thus, patients with prostate disease are treated with long-stay urethral catheters for periods often up to two years. This increases the risk of urethral stricture. The predominant aetiological factor is sexually transmitted infection due to gonococcus or chlamydia. This frequently leads to long severe strictures with spongiofibrosis, especially in the anterior urethra where the periurethral glands are located. These strictures respond poorly to urethral dilatation, optical urethrotomy or primary anastomosis. The majority of strictures in Africa are best treated by open substitution urethroplasty. The gold standard has been the use of buccal mucosa graft for this substitution procedure. This procedure poses a great challenge in most centres with limited resources. In these settings, we have found that the use of a dorsal onlay free preputial graft is easy to perform and gives good results.
Keywords
Rationale
The buccal mucosa graft (BMG) is a wet mucosa of non-keratinised stratified squamous epithelium. This makes it an ideal replacement for the diseased urethra. In our setting, this adds additional operating time and the requirement for the patient to have general anaesthesia and intubation. The preputial mucosa of the foreskin of the uncircumcised penis also a wet mucosa which has similar epithelium to the buccal mucosa (BM). The use of the preputial mucosa graft (PMG) for urethroplasty was described by Barbagli and was shown to produce good results. In this report, we have found the use of PMG easier than BMG.1,2
Method
The urethral stricture is first confirmed by a urethrogram. This will show a long urethral stricture greater than 4 cm, with complete occlusion of the urethral lumen. The technique is best suited for anterior urethral strictures.
Technique
Harvesting the preputial skin
The best result is obtained in a patient who has a full length prepuce covering the whole length of the glans. Studies have shown that unfortunately up to 15% of men have a deficient preputial skin length.
3
The length of the preputial graft required is measured using a tape from a sterile drape. A free graft is excised from the dorsal preputial mucosa ensuring as thin a graft is taken as possible. The skin is closed routinely with interrupted absorbable sutures. Figure 1 shows the outcome from the donor site.
The healed site from which PMG was harvested.
Quilting and placement
The stricture site is prepared by excision of the whole length of the urethral stricture using a standard urethrectomy technique. A raw fresh dorsal bed is left for the placement of an onlay PMG. The graft is spread on a skin graft board and perforated using a surgical knife. The PMG graft is placed as a dorsal onlay graft and secured with 3/0 vicryl sutures centrally and peripherally. This type of dorsal onlay graft is supported by the corpora cavernosa bed and is less prone to complications in comparison to the ventral onlay graft. The graft is left to take and fix for three to six weeks. The patient is taken to theatre after this for the second stage of the urethroplasty (Figures 1–6).
The outcome after PMG graft at 3–6 weeks. A size 18Ch Catheter is inserted over the PMG to start the second stage of the urethroplasty. A wide incision is placed to free the graft edges. The first layer of extra mucosal inversion sutures is placed. The final closure of the urethroplasty is done.
Second stage urethroplasty
The proximal and distal ends of the urethral are dilated to ensure patency. A size 18Ch Foley catheter is placed. Over this, the urethra is closed in two or three layers using 3/0 Vicryl sutures. The first layer is an extramucosal continuous repair. The patient will have a suprapubic catheter for urinary diversion, so that the penile catheter is only a stent and not a drain. The catheter in the penile urethra is removed after three weeks and the suprapubic catheter spigoted to determine urinary flow and patency.
Conclusion
The high prevalence of urethral strictures and their severity in Africa requires innovative approaches to prevent morbidity. The use of a PMG is one way of reducing morbidity caused by urethral stricture disease in low-resource settings. This method has been widely used and shown to be as effective as a BMG. In our low-resource settings in Africa, we have found it much easier to use than a BMG. The patient does not need to have general anaesthesia or intubation for the procedure. Only one team of surgeons is required, operating in one local area and the outcome is good. The technique appears ideal for the settings of sub-Saharan Africa and requires less skills to perform. 4
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.