COMPLICATIONS OF URETHROPLASTY
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HOSAM S. AL-QUDAH,
RICHARD A. SANTUCCI
of Urology, Detroit Receiving Hospital and Wayne State University School
of Medicine, Detroit, Michigan, USA
An extensive study of complications following urethroplasty has never
been published. We present 60 urethroplasty patients who were specifically
questioned to determine every possible early and late complication.
Materials and Methods: Retrospective chart
review of urethroplasty patients between August 2000 and March 2004. An
“open format” questioning style allowed maximal patient reporting
of all complications, no matter how minor.
Results: 60 patients underwent 62 urethroplasties
(24 anterior anastomotic, 19 buccal mucosal and 10 fasciocutaneous, 9
posterior anastomotic) with mean follow-up of 29 months. Early complications
occurred in 40%, but only 3% were major (rectal injury and urosepsis).
Early minor complications included scrotal swelling, scrotal ecchymosis
and urinary urgency. Late complications occurred in 48%, but only 18%
were significant (erectile dysfunction, chordee and fistula). Late minor
complications included a feeling of wound tightness, scrotal numbness
and urine spraying. Fasciocutaneous urethroplasty caused the most significant
complications, and buccal mucus urethroplasty the least, while also resulting
in the lowest recurrence rate (0%).
Conclusions: Serious complications after
urethroplasty (3% early and 18% late) appear similar to those reported
elsewhere, but minor bothersome complications appear to occur in much
higher numbers than previously published (39% early and 40% late). While
all the early complications were resolved and most (97%) were minor, less
than half of the late complications were resolved, although most (82%)
were minor. These complication rates should be considered when counseling
urethroplasty patients, and generally tend to support the use of buccal
mucosal onlay urethroplasty as it had the lowest rate of serious side
words: urethra; urethral stricture; surgery; complications
Int Braz J Urol. 2005; 31: 315-25
has excellent success rates against urethral stricture (1-5), that far
exceed that seen with direct visual internal urethrotomy (DVIU) and dilation
(6,7). The total impact of urethroplasty on the patient is unknown as
an extensive study of complications after urethroplasty has not yet been
published. We present our experience with 60 urethroplasty patients especially
questioned so as to determine every possible early and late complication.
retrospective chart review of 60 consecutive patient who underwent 62
urethroplasty operations between August 2000 and March 2004, including
24 anterior anastomotic, 19 ventral onlay buccal mucosal graft, 10 fasciocutaneous
onlay flap, and 9 posterior anastomotic urethroplasties. In 2 patients,
multiple simultaneous procedures were performed: 1 patient had a proximal
buccal graft plus distal fasciocutaneous flap, another had a proximal
anastomotic plus distal fasciocutaneous flap. The patient mean age was
46 years (18 to 78 years) with a mean follow-up of 29 months (10 to 53
Patients’ records were reviewed regarding
stricture cause, stricture length determined by retrograde urethrogram
(RUG), location, type of urethroplasty, early complications, results of
postoperative urethrogram, postoperative flow rates, late complications
and stricture recurrence. Strictures ranged from 0.5 to 11 cm in length
(mean 2.8 cm) and etiology, location, and treatments varied (Table-1).
All spontaneous complaints were meticulously recorded. Further “open
format” questioning allowed maximum patient reporting of all complications,
no matter how minor. Each patient was asked, “Is there anything
at all bothering you after surgery?” Later, they were prompted with
“Is there anything else you can think of?” Finally, they were
specifically prompted for complaints concerning voiding, sexual function,
wound problems, and mouth problems (after buccal graft harvest).
All patients were operated on by the same surgeon
(RAS). All patients received perioperative antibiotics and were free of
urinary tract infection on the day of surgery. Standard techniques for
urethroplasty were followed, including meticulous tissue handling, watertight
closure, loop magnification and careful high lithotomy positioning.
early complications occurred after 40% of operations and late complications
occurred after 48%. Early complications were major in only 3% of cases
(rectal injury and urosepsis). The majority of early complications were
minor (scrotal swelling ,scrotal ecchymosis and urinary urgency) and all
Not including stricture recurrence, late complications
were major in 18% of cases (erectile dysfunction - ED, chordee and fistula).
Only 9/25 (36%) of the patients with minor late complications (feeling
of wound tightness, scrotal numbness and urine spraying) resolved spontaneously
or with medication. Stricture recurrence occurred after 10% of operations.
Among patients with anterior anastomotic urethroplasty,
25% and 54% had early and late complications respectively (Table-2). None
of the patients had early major complications and 5/24 (20%) of them had
late major complications. For patients with posterior urethroplasty, 56%
(early) and 44% (late) had complications, and 2/9 (22%) patients had late
major complications (Table-3). For buccal mucosal onlay patients, 37%
had early and late complications. 1/19 (5%) of the early and 0/19 (0%)
of the late patients had serious complications (Table-4). Fasciocutaneous
urethroplasty patients had 60% early and late complications. 1/10 (10%)
and 4/10 (40%) of the patients had serious early and late complications
and late effects of urethroplasty, including complications, have not been
extensively reported in the literature. They are usually discussed as
part of broader reports of operative outcomes that generally concentrate
on rates of surgical success, and only discuss the most easily recognized
complications such as erectile dysfunction and incontinence. Compared
to these other studies, our data indicate a high degree of patient complaints,
likely because our method of inquiry encouraged the voicing of all possible
concerns, and, in this method, some minor issues that would not be considered
true “complications” are reported. When other centers determined
complication rates by direct inquiry, the reported rates of complications
also increased. In a report of ED after anterior anastomotic urethroplasty
from a single center determined first by chart review, (2) then later
by patient questionnaire, (8) ED rates rose from < 1% to 27%.
Overall, 40% of our patients had early complications
and 48 % had late complications. The complication rate differed by urethroplasty
type, as has been previously reported (9,10). For example, in our series
the rate of serious complications after anterior anastomotic urethroplasty
was 21%, while that for fasciocutaneous onlay urethroplasty was 40%. This
corresponds to results already published. Andrich et al. (11) reported
a significantly higher rate of complications after fasciocutaneous urethroplasty
(33%) compared to anastomotic urethroplasty (7%).
Only 2 series report complications with enough
detail to compare directly to our data. Complications after anastomotic
urethroplasty were published from University of California-San Francisco
(UCSF) (2) (Table-6) and detailed complications of 84 fasciocutaneous
urethroplasty were published from the Institute of Urology in London (Table-7)
(11). The UCSF series showed a comparable degree of nuisance complications
but they differed in their makeup (Table-6) and showed a much lower rate
of ED than seen in our series. This may be due to incomplete questioning
of the patients, as this rate climbed sharply when this group later specifically
queried the patients about erectile dysfunction (8). The London series
also showed some of the same complications we have seen (such as post
void dribbling), while in their series urinary tract infection (UTI) and
urethral diverticula were seen there, but not in our data. In general,
we report a significantly higher overall rate of complications than that
reported elsewhere, even when minor complications are not counted (Tables-8,
9, 10, 11).
Minimal urinary leakage after voiding was common
and may be an expected result of decreased urethral elasticity as a result
of stricture disease or its treatments. It is so common that likely all
patients should be warned before urethroplasty surgery, as surgery seems
to cause or unmask it clinically in a certain percentage.
We had positional complications in only one patient
(2%) who had temporary hand numbness. None of our patients reported thigh
numbness. Previous reports have generally shown a higher percentage of
positional complications than seen in our series, ranging between 10-20%
(12,13). We attribute our low rates to surgery times that were kept as
short as possible and the evolution of meticulous positioning protocols
over time using multiple aids including a gel-padded bean bag, sequential
compression devices, compression stockings, and arm padding, all which
have been previously described (2).
Success rates varied by urethroplasty type (Tables-2,
3, 4, 5, 12). Ventral buccal mucosal onlay had the highest success rate
(100%), even when used against reasonably long strictures (mean stricture
length was 3.4 cm). Posterior anastomotic urethroplasties also had a 100%
success rate over the observation period. The next most successful was
anterior anastomotic urethroplasty (92%) for mean stricture length of
1.6 cm. Fasciocutaneous urethroplasty had the lowest success rate (60%)
and was of course used only against the longest strictures (mean 5.7 cm).
This study has 2 limitations. The first is that
some groups have small numbers (9 patients in the posterior anastomotic
group) but overall we believe it gives a good overview of the expected
sequellae of a wide range of urethroplasty surgery operations. The second
is that it is retrospective in nature, and while we understand the theoretical
advantage of prospective versus retrospective studies, it is not certain
that a prospective study would give any more accurate results than we
have obtained here.
follow up of post urethroplasty surgery patients shows a high percentage
of early and late complications, although many of these are minor in scope.
Serious complications (3% early and 18% late) appear similar to those
reported elsewhere, but minor bothersome complications appear to occur
in much higher numbers than previously published (39% early and 40% late).
All early complications were resolved and most (97%) were minor, but less
than half of the late complications were resolved and a lower percentage
(82%) was minor. A full reckoning of the impact of urethroplasty surgery,
including these minor complaints that nonetheless bother the patient will
help the patient and surgeon understand the full implications of planned
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Received: June 17, 2005
Accepted: June 28, 2005
Dr. Richard A. Santucci
Detroit Receiving Hospital
4160 John R. Suite 1017
Detroit, Michigan, 48201, USA
Fax: + 1 313 745-0464
is an interesting retrospective analysis of extensive early and late complications
after urethroplasties performed by the same experienced surgeon (RAS).
Although the manuscript tried to add new information to the literature
of complications after urethral surgery, several concerns and issues have
to be considered.
the 60 consecutive patients enrolled in the analysis cannot be considered
a homogeneous group. The authors included patients with anterior and posterior
urethral strictures, with different etiologies, with a wide range in length,
and, furthermore, they used different techniques. No surgery was performed
for repairing strictures in patients with hypospadias failure and no dorsal
onlay buccal mucosa grafts were done in this series. Ruling out these
2 conditions could represent a significant limitation to reporting complications.
I suggest that the main criteria for studying early and late complications
are a homogeneous group of patients chosen according to selective criteria.
points of interest include the relatively small sample size, which the
authors correctly mention in the discussion, and the short-term follow-up.
The mean follow-up was reported to be 29 months with a range between 10-53
months. Long-term follow-up (5 years) is important in estimating the rates
of recurrence (late complications). The longer and more you follow patients
after surgery, the less you will be satisfied with your results, although
these results are considered quite good after 2 years.
the reader, the method of studying the complications appears vague, excessively
subjective and imprecise. The authors investigated only the local perineal
and urethral complications, forgetting the oral complications after buccal
mucosa graft (BMG), which they performed on 19 patients. BMG has emerged
as safe and reliable material for urethral reconstruction but the morbidity
associated with harvesting BMG is still an open problem (1). Recently,
Barbagli investigated the early and late complications after BMG harvest
from a cheek in a homogeneous series of 90 patients (2). He used a closed
questionnaire administered by telephone by a neutral person not on the
staff of the hospital, which included 6 questions designed to investigate
the early (first 10 postoperative days) complications and 14 questions
to investigate the late ones. The early complications were bleeding (4%),
pain (21%) and swelling (42%). The main late complication was perioral
numbness for 1 month (34%), while no significant discomfort due to the
scar, difficulty with mouth opening, difficulty in smiling or changes
in the face physiognomy were reported.
conclusion, the choices that are available to reconstruct the urethra
are continuously developing and focused attention is required to old and
new concepts. The successful management of urethral strictures, which
in other words means an increase of long-term positive outcome and a low
rate of complications, is demanding for reconstructive surgeons and it
depends on different factors, including surgical skill as well as the
right criteria for patient and surgery selection. Certainly, the use of
a fasciocutaneous flap or graft should not compromise penile length, should
not cause chordee and should not affect penile appearance. Oral morbidity
should be considered after BMG in order to avoid permanent late sequel
in mouth function. Finally, sexual function can be placed at risk by any
urethral surgery and any dissection, especially for posterior urethral
reconstruction, should avoid interference with the neurovascular bundles
to the penis.
1. Armenakas NA: Long-term
outcome of ventral buccal mucosal grafts for anterior urethral strictures.
AUANews. 2004; 9(3): 17.
2. Barbagli G, Palminteri E, Guazzoni G, Turini D, Lazzeri M: The morbidity
of buccal mucosa graft harvest from cheek in 90 adult patients J. Urol.
2005; 173 (suppl.), 33: Abst. 122.
Dr. Massimo Lazzeri
Department of Urology
Casa di Cura Santa Chiara Firenze
Limiting Complications from Urethroplasty
from urethral reconstruction may occur either in relation to the local,
technical nature of the repair (re-stenosis, dribbling, spraying, scrotal
numbness, skin necrosis) or to high lithotomy positioning (lower extremity
compartment syndrome, neuropraxia, rhabdomyolysis). There is no question
that expertise in urethral reconstruction reduces the incidence of both
conditions and that longer strictures are more problematic than short.
most important thing we have done to reduce position-related complications
has been to avoid prolonged leg elevation at all costs. Our comprehensive
literature review on this subject published in 2000 (reference 12 in the
article) indicated clearly that high lithotomy-related complications occur
predominantly during procedures lasting 5 hours or longer. We have since
adopted a “5-hour rule” for high lithotomy positioning that
has completely eliminated this problem in our practice. For complex cases,
we proceed in a distal-to-proximal manner with the patient supine, elevating
the legs only when necessary to reach the perineum. In panurethral reconstructions,
we often re-prep and re-drape at the halfway point after repositioning.
are better than penile skin flaps for bulbar urethral reconstructions because
they are equally efficacious and much more efficient technically. By harvesting
the buccal grafts at the beginning of the case with the patient in the supine
position, the legs may be elevated, again, only when exposing the perineum.
reduce stricture recurrence from anastomotic and posterior urethroplasty,
the key is to adequately excise all periurethral fibrotic tissue. I like
to use multiple traction sutures in the scar to “lift” it out
(as taught by Dr. McAninch) in a way that a 28F bougie passes easily. Tension-free
anastomosis is accomplished by extensively mobilizing the distal urethral
segment from its scrotal attachments, especially on its ventral aspect where
no blood supply exists.
reduce stricture recurrence from graft and flap procedures, the question
that must be asked is, “What am I patching on to?” I suspect
many failures occur due to an inadequate urethral plate and often try to
“salvage” a deficient plate by mobilizing, excising, and/or
grafting until the plate is approximately 1 cm wide.
Dr. Allen F. Morey
Chief of Urology, Brooke Army Medical Center
Urology Service, MCHE-SDU
Fort Sam Houston, Texas, USA