PMC4519531_01
Preoperative retrograde urethrogram and attempted voiding cystogram.
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Three months later he presented for reevaluation with a voiding retrograde urethrogram and attempted voiding cystourethrogram (Figure 1).
Steps of the Stage 1 procedure. (a) Patient positioned with access to the perineum and the left inner thigh, (b) transection of the affected urethral plate, (c) dorsal plate augmented with buccal mucosa, (d) augmented perineal urethrostomy with catheter in place (preparation for the tie-over dressing), (e) exposed distal gracilis, and (f) buccal mucosa quilted on the gracilis.
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After appropriate informed consent was obtained, the patient underwent a general anesthesia, administered IV Cefazolin and Gentamycin, placed in a low lithotomy position, prepped, and draped in a manner allowing access to the perineum and the left inner leg (Figure 2(a)). The fistula and the affected urethra were dissected and removed leading to a 6 cm defect (Figure 2(b)). Two 6 x 2.5 cm buccal mucosal grafts were harvested, defatted, and fenestrated (Figure 2(c)). A perineal urethrostomy was matured by approximating edges of skin to the edges of neourethral plate (Figure 2(d)). During the same operation, the left gracilis tendon was identified and a 6 x 2.5 cm elliptical skin defect was created just proximal to the tendon (Figure 2(e)). The second harvested buccal graft was quilted on the exposed muscle with 4-0 polydioxanone sutures and a tie-over dressing and an elastic bandage around the leg were applied for one week (Figure 2(f)).
Steps of the Stage 2 procedure. (a) Engrafted perineal urethrostomy at 8 weeks, (b) dorsal plate dissected, (c) gracilis-buccal mucosa composite harvest, (d) gracilis tunneled into the perineal incision, (e) dorsal (left) and ventral (right) plates anastomosed on the left side, and (f) completed anastomosis of ventral and dorsal hemi-plates.
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Eight weeks after the first stage, both grafts appeared to have taken well with no signs of a contracture or stenosis of the urethrostomy (Figure 3(a)). The perineal urethrostomy was freed by incising the skin just around the edges of the buccal graft (new dorsal hemi-plate) and dissecting laterally away from the graft (Figure 3(b)). The muscle was circumferentially dissected proximally and distally and its tendon transected (Figure 3(c)). The muscle-graft composite was passed through a wide tunnel into the perineal incision and the BMG edges on the flap (new ventral plate) were approximated apex-to-apex to the edges of the dorsal graft with running 4-0 polydioxanone sutures (Figures 3(d)-3(f)).
Voiding cystourethrography at 5 weeks.
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He had retrograde and antegrade imaging studies in the office at 3 weeks demonstrating a small contrast extravasation which had resolved by 5 weeks at which point his urethral catheter was removed (Figure 4).
Urethroscopy at 8-month follow-up.
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On the office cystoscopy at 8-month follow-up the patient demonstrated patent anastomotic sites and a patulous neourethral segment circumferentially lined with healthy appearing buccal mucosa (Figure 5).