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Similar treatment for fistulae |
Widening urethral strictures by the roof
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LETTER TO MY FRIENDS UROLOGICAL SURGEONS who feel concerned by the endemic male urethra stricture |
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Dear colleagues,
Owing to the everlasting difficulty of gaining a really permanent healing of the disease, several of us asked me for more and clearer explanations on the surgical technique I proposed in 1967. Yet the proper principle of action had been clearly defined during the nineties. After centuries of searches for a convenient knife, the french Maisonneuve, just before his death in 1875, built a new flexible urethrotome with a dorsally oriented blade that could definitely solve the problem. At that time they continued indeed to believe that severing a fibrous ring would enlarge the tube at the point of stricture and that the good Nature would do. There is no belief more silly than this. In fact the urethra is a tube made of helicoidal bundles of elastic fibers. Whatever bundles you cut, you free the elasctic power of all others and the stricture recurs at once, worsened by the unavoidable retractile fibrous scar you have inflicted. Nevertheless controlling the Maisonneuve’s urethrotomy by urethroscopy introduced a quite new, revolutionary view of the surgical treatment. It became soon obvious that the new urethral roof appearing beyond the dorsal incision, i.e. the albugineous envelope of the corpora cavernosa, could readily support the growth and spreading of a new urethal epithelium. Thus, in order to fill the missing urethral surface : 1) split the roof of the strictured urethra longitudinally beyond the stricture 2) dilate properly the canal with a soft metallic bougie 3) let a good caliber catheter in place until the lips of the incision stick firmly to the surrounding tissues 4) During two or three weeks after that, control by urethroscopy the regrowth of a new epithelial layer and tear possible superficial adherences.
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This is the only acceptable principle for widening a strictured urethra. No other tissue than the corpora cavernosa can afford the elasticity that is required for both erection and detumescence. Unfortunately putting the principle into practice encounters many disappointments. This is due to the lack of preciseness of a technique that was conceived during the nineteenth century for the general practioner in his office. I proposed in 1967 a surgical technique aiming to perform all what Maisonneuve could not achieve with his urethrotome : a) a perfectly precise, well-ordered and controlled operation for the urologist surgeon. b) Opportunity for removing the nests of septic recurrence. --------- Please have a look at the drawings below. Allow me to insist on three points : 1) Whenever feasible get access to the Cowper’s glands and clean them of all septic remanence. 2) Keep in mind that erectile tissues sustain blood tensions that could be higher than the maximum aortic pressure. Therefore suture the male urethra with the same care you would afford to the aorta, knowing that no drug could impede steadily along hours and days the erection over the indwelling catheter. 3) Please aknowledge that a strictured patient cannot be repaired and sent home like a car. Please do not kneel down before the money-grabbing mentality of the financial chiefs, or of your colleagues, or even of yourself. Devote required time and operation rooms to your patient as you swore once upon a time .
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PERSONAL TECHNIQUE
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Surgical principles
I designed this operation according to these requirements :
1) It must be a plasty intended for filling the urethral gap 2) It must be done within a single anesthesia 3) The substitution tissue must fulfil these specifications : - same extensibility as corpus spongiosum during erection - new mucosa devoid of secretion and urinary stone possibility 4) No circular suturing for no circular narrowing 5) No remaining diverticula nor recessus 6) No penis shortening 7) No cystotomy nor cystostomy 8) No penile scar or frozen skin 9) No operative endangering of the erectile bodies blood vessels 10) No damage to the bulbo-cavernous muscles
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OUTLINE
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Similar treatment for fistulae |
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a) The urethra is freed from the above fibrous layer
b) The urethal incision is made dorsally and medially in the sagittal plane, over the strictured area, extended markedly to the healthy areas upwards and downwards
c) A large urethral catheter being in place, the right and left lips of the incision are tied to the above fibrous plane, i.e. the albugunea of the cavernous bodies whose gutter-like shape affords a tubular reconstruction of the canal. At the levels of glans penis and of the bulbo-membranous urethra, the same function is performed respectively by the glans upper ligament and by the triangular ligament. |
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Penile and balanic urethra
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The incision is done in the balano-preputial fold whose scar is invisible. |
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Scrotal, scroto-bulbo-membranous, membranous urethra
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Skin incision on the bulbar bulge. |
Dissection starts from the angles between the urethra and the insertions of the bulbo-cavernous muscles. They are carefully preserved. |
Dissection must be carried on unto the membranous urethra through the bulbar suspensor ligament beyond the triangular ligament in order to lance the Cowper's glands abscesses. |
Pulling heavily the penis upwards while suturing is mandatory in order to prevent some shortening of the erect penis. |
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The technique applies to the traumatic strictures of the membranous urethra in pelvic bone fractures provided the pre-prostatic ligament be preserved or cleanly resutured.
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Left, the support catheter before suturing
Right, suture of the incision lips to the supra-urethral gutter sides |
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NOTA BENE
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1) The suture thread must be strong and rather thick. Fine threads cut tissues and break. Breaking of threads ensures operation failure.
2) Most of thread breakings occur soon after operation, on the stretcher between theater and bed, when the patient is awakening and develops a painful erection on the sound. It must be kept in mind that such erections display an inner blood pressure higher than the aortic tension. Strong threads in clear-cut stitches and pain drugs are mandatory.
Above : recurring stricture after breaking of a stitch.
3) Do not forget the Cowper's glands. Their abscesses keep the stricture process going on.
4) The urethral sound is left in place for 10 to 12 days. It is obvious and clear that during the following days the raw surfaces tend to stick . Nevertheless the vividness of the urinary mucosa is so outstanding that a new epithelial covering spreads quickly, that avoids adhesions, provided that incipient adherences be torn by a smooth Beniqué bougie, 3 or 4 times during the following 3 weeks.
5) The radiographic image is nothing more than an accessory document. Only open operation can make the inventory of the tissue damages. Inversely, superficial mucosal adhesions could be taken for real strictures. That can explain rare successes and centuries-old survival of the bougie dilators. True strictures never heal : they go on narrowing.
6) Dysuria by itself is no proof of stricture nor a witness of operation failure since it may originate notably in concommittant prostate or bladder neck diseases.
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The operation steps drawings are from Rudi Pillen ( see his website )
