Surgical treatment of bulbar urethral strictures: tips and tricks

ABSTRACT The surgical treatment of bulbar urethral strictures is still one of the most challenging reconstructive-surgery problems. Bulbar urethral strictures are usually categorized as traumatic and non-traumatic strictures depending on the aetiology. The traumatic strictures are caused by trauma and they determine disruption of the urethra with obliteration of the urethral lumen, ending with fibrotic gaps between the urethral ends. Differently, the non-traumatic urethral strictures are mainly caused by catheterization, instrumentation, and infection, or they can also be idiopathic. They are usually associated with spongiofibrosis of the segment of the urethra that has been involved. Worldwide, two different surgical approaches are currently adopted for bulbar urethral repair: transecting techniques with end-to-end anastomosis and non-transecting techniques followed by grafting. Traumatic obliterated strictures require transection of the urethra allowing complete removal of the fibrotic tissue that involves the urethral ends. Conversely, non-traumatic, non-obliterated urethral strictures require augmentation of the urethral plate using oral mucosa grafts. Nowadays, it is still difficult to choose the correct surgical management for non-obliterated bulbar stricture repair. Indeed, different surgical techniques have been proposed (pedicled flap vs free graft, dorsal vs ventral placement of the graft, non-transecting technique using or non-using free graft, etc.) but none emerged as the best solution since all techniques have showed similar success and complication rates. Consequently, the final choice is still based on surgeon’s preferences and patient’s characteristics. Within the current manuscript, we like to present some of our tips and tricks that we developed along our prolonged surgical experience on the treatment of bulbar urethral strictures. These might be of interest for surgeons that approach this complex surgery. Moreover, our suggestions want to be useful regardless the type of chosen technique being adaptable for different scenario.

摘要 球部尿道狭窄（bulbar urethral strictures）的外科治疗仍是重建外科（reconstructive surgery）领域最具挑战性的手术难题之一。根据病因学（aetiology），球部尿道狭窄通常可分为创伤性与非创伤性狭窄两类：创伤性狭窄由外伤引发，可导致尿道断裂、尿道腔闭塞，最终在尿道断端之间形成纤维化间隙；与之相对，非创伤性尿道狭窄主要由导尿术、器械操作及感染所致，亦可表现为特发性狭窄，此类狭窄常累及的尿道段并伴随该段尿道的海绵体纤维化（spongiofibrosis）。目前全球临床中，球部尿道修复主要采用两类手术方案：一是行尿道切断后端端吻合的切断式技术，二是不切断尿道联合移植的非切断式技术。创伤性闭塞性狭窄需行尿道切断术，以彻底切除累及尿道断端的纤维化组织；反之，非创伤性非闭塞性尿道狭窄则需借助口腔黏膜移植物（oral mucosa grafts）扩大尿道板。时至今日，针对非闭塞性球部尿道狭窄的手术方案选择仍颇具难度：诚然，学界已提出多种手术策略（如带蒂皮瓣与游离移植物的对比、移植物背侧与腹侧放置的对比、是否应用游离移植物的非切断式技术等），但由于各类术式的成功率与并发症发生率均无显著差异，尚无一种术式被公认为最优解决方案，因此最终术式的选择仍取决于术者的个人偏好与患者的个体特征。在本手稿中，我们将分享基于长期球部尿道狭窄诊疗手术经验总结的若干操作技巧与心得，以期为开展此类复杂手术的外科医师提供参考；此外，我们的建议不受所选术式类型的限制，可适配不同的临床场景。