Muscle- and nerve-sparing bulbar urethroplasty: a new technique.

Abstract

To describe a new surgical technique for the repair of bulbar urethral strictures to preserve the bulbospongiosum muscle and its perineal innervation.
Surgical steps of muscle- and nerve-sparing bulbar urethroplasty are described. The outcome is provided regarding semen sequestration and postvoiding dribbling.
We performed the procedure in 12 patients (average age: 43.58 yr) with bulbar urethral strictures (average stricture length: 4.47 cm).
Six patients underwent urethroplasty using a ventral oral mucosal onlay graft, and six patients underwent urethroplasty using a dorsal oral mucosal onlay graft. In all patients, the surgical approach to the bulbar urethra was made avoiding dissection of the bulbospongiosum muscle from the corpus spongiosum and leaving the central tendon of the perineum intact.
Clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the technical feasibility of the muscle- and nerve-sparing bulbar urethroplasty. The secondary outcome examined the presence or absence of postoperative postvoid dribbling and semen sequestration using a nonvalidated questionnaire (Appendix).
In all patients, postoperative voiding cystourethrography was performed 3 wk after surgery and no urethral sacculation was evident. Urethrography were repeated after 6 mo and 12 mo. No postvoid dribbling or semen sequestration was demonstrated in all patients at 6 mo and 12 mo after surgery. No patient showed stricture recurrence. The average follow-up was 15.25 mo (range 12 mo to 26 mo, median 13.5 mo).
Bulbar urethroplasty preserving the bulbospongiosum muscle, the central tendon of the perineum, and the perineal nerves is a safe, feasible, minimally invasive alternative to traditional bulbar urethroplasty.

Full text

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Surgery in Motion
Muscle- and Nerve-sparing Bulbar Urethroplasty:
A New Technique
Guido Barbaglia, Stefano De Stefanib, Filippo Anninob,*, Cosimo De Carneb,
Giampaolo Bianchib
aCenter for Reconstructive Urethral Surgery, Arezzo, Italy
bDepartment of Urology, University of Modena-Reggio Emilia, Modena, Italy
european urology 54 (2008) 335–343
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Article info
Article history:
Accepted March 7, 2008
Published online ahead of
print on March 24, 2008
Keywords:
Urethra
Urethroplasty
Bulbospongiosum muscle
Perineal nerve
Central tendon of the
perineum
Abstract
Background: Todescribeanewsurgicaltechniquefortherepairofbulbarurethral
strictures to preserve the bulbospongiosum muscle and its perineal innervation.
Objective: Surgical steps of muscle- and nerve-sparing bulbar urethroplasty are
described. The outcome is provided regarding semen sequestration and post-
voiding dribbling.
Design, Setting, and Participants: We performed the procedure in 12 patients
(average age: 43.58 yr) with bulbar urethral strictures (average stricture length:
4.47 cm).
Surgical Procedure: Six patients underwent urethroplasty using a ventral oral
mucosal onlay graft, and six patients underwent urethroplasty using a dorsal
oral mucosal onlay graft. In all patients, the surgical approach to the bulbar
urethra was made avoiding dissection of the bulbospongiosum muscle from the
corpus spongiosum and leaving the central tendon of the perineum intact.
Measurements: Clinical outcome was considered a failure when any postopera-
tiveinstrumentationwasneeded.Theprimaryoutcomeexaminedthetechnical
feasibility of the muscle- and nerve-sparing bulbar urethroplasty. The second-
ary outcome examined the presence or absence of postoperative postvoid
dribbling and semen sequestration using a nonvalidated questionnaire (Appen-
dix).
Results and Limitations: In all patients, postoperative voiding cystourethrography
was performed 3 wk after surgery and no urethral sacculation was evident.
Urethrography were repeated after 6 mo and 12 mo. No postvoid dribbling or
semen sequestration was demonstrated in all patients at 6 mo and 12 mo
after surgery. No patient showed stricture recurrence. The average follow-up
was 15.25 mo (range 12 mo to 26 mo, median 13.5 mo).
Conclusions: Bulbar urethroplasty preserving the bulbospongiosum muscle, the
central tendon of the perineum, and the perineal nerves is a safe, feasible,
minimally invasive alternative to traditional bulbar urethroplasty.
# 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Department of Urology, University of Modena-Reggio Emilia,
L.go del Pozzo, 71, 41100 Modena, Italy. Tel. +39 059 4224766; Fax: +39 059 4222863.
E-mail address: f_annino@hotmail.com (F. Annino).
0302-2838/$ – see back matter # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.doi:10.1016/j.eururo.2008.03.018

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1.Introduction
Urethral sacculation causes postvoiding dribbling,
which is a natural complication of any kind of
unsupported graft or flap anterior substitution
urethroplasty. The mechanical weakening of the
unsupported grafted area is evident on postopera-
tive voiding cystourethrography because retrograde
urethrography may fail to show urethral sacculation
[1]. Surprisingly, the clinical evidence of postvoiding
dribbling may also occur in patients who underwent
bulbar urethroplasty but who also showed a normal
voiding cystourethrography [1]. In 2005, we decided
to include a nonvalidated telephone questionnaire
(Appendix) in our follow-up study to investigate the
prevalence of postoperative sexual and urinary
dysfunction following one-stage anastomotic or
substitution bulbar urethroplasty.
In 60 of 153 patients who underwent bulbar end-
to-end anastomosis, 12 patients (20%) experienced
decreased force of semen emission; for 2 patients
(3.3%), ejaculation was possible only by manually
compressing the perineum at the level of the
urethral bulb [2]. In 67 of 210 patients who under-
went one-stage substitution urethroplasty using
oral mucosal grafts, 20 patients (29.8%) showed
decreased force of the semen emission; 34 patients
(50.7%) showed some degree of postvoiding drib-
bling (unpublished data). Fortunately, these minor
postoperative dysfunctions did not modify the
overall satisfaction of the surgery, and this optimis-
tic patient evaluation is also probably influenced by
the good outcome obtained with the regard to
urinary function [2]. Moreover, postvoid dribbling
and semen sequestration will likely be a post-
operative complication following any bulbar ure-
throplasty [2].
The surgical approach to reach the bulbar urethra
includes extensive dissection of the bulbospongio-
sum muscle, and sectioning of the central tendon of
the perineum is suggested for proximally located
bulbarstrictures.Recently,
hypothesis that in some patients, postvoid dribbling
and loss of semen emission could be caused by
neural damage to the bulbospongiosum (bulboca-
vernosus) muscle or to the perineal nerves during
their dissection in preparation of the bulbar urethra
[1,2].
In this article, we describe a new oral mucosal
onlay graft bulbar urethroplasty that preserves the
bulbospongiosum muscle, the central tendon of the
perineum, and the perineal nerves to reduce the risk
of postvoiding dribbling and loss of semen emission,
thus improving patient quality of life following
bulbar urethroplasty.
wesuggestedthe
2. Patients and methods
2.1. Patient population
Twelve patients with an average age of 43.58 yr (range: 37 to
69 yr, median 40.5 yr) underwent bulbar urethroplasty using
an oral mucosal graft while preserving the bulbospongiosum
muscle and the central tendon of the perineum. Preoperative
evaluation included clinical history, physical examination,
urine culture, residual urine measurement, uroflowmetry,
urethral ultrasound, and retrograde and voiding cystoure-
thrography. The stricture etiology was previous urethral
instrumentation in five cases (41.66%) and unknown in seven
cases (58.33%). Patients with lichen sclerosis or failed
hypospadias repair were excluded. Stricture length was 3 to
4 cm in five patients (41.7%), 4 to 5 cm in four patients (33.3%),
and 5 to 6 cm in three patients (25%). The average stricture
length was 4.47 cm (range: 3 to 6 cm, median 4.45 cm). Ten
patients (83.3%) had undergone dilation or internal urethro-
tomy before referral to our center.
2.2.Surgical techniques
Six patients underwent urethroplasty using a ventral oral
mucosalonlaygraft,andsixpatientsunderwenturethroplasty
using a dorsal oral mucosal onlay graft. The dorsal location of
the graft was selected for long distal strictures, whereas the
ventral graft location was selected for shorter proximal
strictures.
The patient is placed in a simple lithotomy position. The
patient’s calves are carefully placed in Allen stirrups with
sequential inflatable compression sleeves, and the lower
extremitiesarethensuspendedbythepatient’sfeetwithinthe
boots of the stirrups. Proper positioning ensures that there is
no pressure on any aspect of the calf muscles and no inward
boot rotation so as to avoid perineal nerve injury. The skin of
the suprapubic region, scrotum, and perineum is shaved, and
this region is prepared and draped appropriately. The oral
mucosal graft is harvested from the cheek according to the
standard technique [3].
2.3.Ventral oral mucosal onlay graft urethroplasty
Methylene blue is injected into the urethra to better define the
urethral mucosa. A midline perineal incision is made. The
bulbospongiosum muscle is separated from the corpus
spongiosum of the bulbar urethra using delicate, smooth
scissors, leaving the lateral margins of the muscle and the
central tendon of the perineum intact (Fig. 1A). The muscle is
pulled down using two small Farabeuf retractors, and the
ventral urethral surface is fully exposed (Fig. 1B). The distal
extent of the stenosis is identified, the corpus spongiosum is
incised along the ventral midline, and the urethral lumen is
fully exposed (Fig. 1C). The stricture is then incised along its
entire length by extending the urethrotomy distally and
proximally.
Once the entire stricture has been incised, the length and
width of the remaining urethral plate are measured. The oral
mucosal graft is trimmed to its appropriate size according to
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Fig. 1 – Ventral oral mucosal onlay graft urethroplasty: (A) The bulbospongiosum muscle is separated from the corpus
spongiosum leaving the lateral margins of the muscle and the central tendon of perineum intact. (B) The bulbospongiosum
muscle is pulled down, exposing the ventral urethral surface. (C) The corpus spongiosum is opened along the midline, and
the ventral urethral surface is fully exposed. (D) The oral mucosal graft is sutured to the proximal and distal apices and to
the left margin of the urethral mucosal plate. (E) The graft is rotated and sutured to the right margin of the mucosal urethral
plate. (F) The corpus spongiosum is closed over the graft, and fibrin glue is injected over the corpus spongiosum. (G) The
bulbospongiosum muscle is picked up to cover the corpus spongiosum.
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Fig. 2 – Dorsal oral mucosal onlay graft urethroplasty: (A) The bulbar urethra is dissected from the corpora cavernosa, leaving
the bulbospongiosum muscle and the central tendon of the perineum intact. (B) The urethra is rotated 180 degrees, and the
dorsal urethral surface is fully opened. (C) The urethra is moved to the right side, and fibrin glue is injected over the corpora
cavernosa. (D) The graft is fixed over the fibrin glue bed. (E) The distal and proximal apices of the graft are sutured to the
apices of the urethrotomy. (F) The urethra, with the intact bulbospongiosum muscle, is rotated to cover the graft. (G) The
graft is covered by the urethra, and fibrin glue is injected over the urethra.
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the length and width of the urethrotomy. The two ends of the
graft are sutured to the proximal and distal apices of the
urethrotomy, and running 6-0 polyglactin suture is used
to complete a watertight anastomosis between the left
margin of the graft and the left margin of the urethral
mucosal plate (Fig. 1D). A Foley 16-French grooved silicone
catheter is inserted.
The graft is rotated over the catheter, and running
6-0 polyglactin suture is used to complete a watertight
anastomosis between the right margin of the graft and the
right margin of the mucosal urethral plate (Fig. 1E). After
completion of graft suturing, the corpus spongiosum is closed
over the graft with 4-0 polyglactin interrupted suture and 2 ml
of fibrin glue are injected over the corpus spongiosum (Fig. 1F).
The bulbospongiosum muscle is picked up to cover the
spongiosum tissue (Fig. 1G). Colles’ fascia, the perineal fat,
and the skin are closed with interrupted absorbable sutures.
The catheter is left in place for 3 wk.
2.4.Dorsal oral mucosal onlay graft urethroplasty
Methylene blue is injected into the urethra to better define the
urethral mucosa. A midline perineal incision is made. The
bulbar urethra is dissected from the corpora cavernosa
starting from the distal tract where muscles are absent,
leaving the bulbospongiosum muscle and the central tendon
of the perineum intact (Fig. 2A). The urethra is rotated
180 degrees, the distal extent of the stenosis is identified,
the dorsal urethral surface is incised along the midline, and
the urethral lumen is exposed (Fig. 2B). The stricture is then
incised along its entire length by extending the urethrotomy
distally and proximally.
Once the entire stricture has been incised, the length and
width of the remaining urethral plate is measured. The oral
mucosal graft is trimmed to an appropriate size according to
thelengthandwidthoftheurethrotomy.Thebulbarurethrais
movedtotherightside,and2 mloffibringlueareinjectedover
the albuginea of the corpora cavernosa (Fig. 2C) [4]. The oral
mucosal graft is fixed over the fibrin glue bed (Fig. 2D) [4]. The
two apices of the graft are sutured to the proximal and distal
apices of the urethrotomy (Fig. 2E). A Foley 16-French grooved
silicone catheter is inserted.
The bulbar urethra, with the intact bulbospongiosum
muscle, is rotated to its original position over the graft
(Fig. 2F). Three interrupted 4-0 polyglactin sutures for each
side are used to stabilize the urethral margins to the corpora
cavernosa over the graft. At the end of the procedure, the graft
is completely coveredby the urethra,thenby the muscles,and
2 ml of fibrin glue are injected over the urethra to prevent
urinary leakage (Fig. 2G) [4]. Colles’ fascia, the perineal fat, and
the skin are closed with interrupted absorbable sutures. The
catheter is left in place for 3 wk.
2.5.Postoperative care and follow-up criteria
The patient ambulates on the first postoperative day and is
discharged from the hospital 3 d after surgery. All patients
receive postoperative broad-spectrum antibiotics and are
maintained on oral antibiotics until the catheter is removed.
Three weeks after surgery, the bladder is filled with contrast
medium, the Foley catheter is removed, and voiding cystour-
ethrography is obtained.
Six and 12 mo after surgery, the prevalence of post-
operative sexual and urinary dysfunction were investigated
using a nonvalidated questionnaire (Appendix).
3.Results
The mean operative time was 90 min (range 80 to
110 min). No intraoperative or postoperative com-
plications were observed. Clinical outcome was
considered a failure when any postoperative instru-
mentation was needed, including dilation. In all
patients, postoperative voiding cystourethrography
was performed 3 wk after surgery and no urinary
leakage was present.
Uroflowmetry and urine culture were repeated
every 4 mo in the first year and annually thereafter.
When symptoms of decreased force of stream were
present and uroflowmetry was less than 14 ml/sec,
urethrography, urethral ultrasound, and urethro-
scopy were repeated. The average follow-up was
15.25 mo (range 12 to 26 mo, median 13.5 mo). No
patient showed stricture recurrence or urethral
sacculation on voiding urethrography.
With regard to the prevalence of postoperative
ejaculation disorders and postvoiding dribbling,
investigatedusingthe
questionnaire, no patient showed decreased force
of semen emission or postvoiding dribbling at 6 mo
and 12 mo after surgery. Of six patients, none
declared that he was dissatisfied with the outcome
of the surgery.
nonvalidated telephone
4.Discussion
The corpus spongiosum of the urethra, the bulbos-
pongiosum muscle, and their functioning are rarely
fully investigated. The bulbospongiosum muscle is
a striated muscle located in the perineum, wrapped
around the big bulb of the urethra. Its function is to
propel seminal fluid during ejaculation. In 1962, the
original studies of Kollberg et al established this
muscle as primarily responsible for ejaculation [5].
Rhythmic contractions of the bulbospongiosum
muscle and other perineal muscles expel semen
from the urethra and probably have an important
roleinexpellingurine,avoidingurinesequestration
in the large urethral bulb following micturition.
The pudendal nerve is the major somatic path-
way of the male genitalia, which consists of three
major branches: the dorsal nerve of the penis, the
inferior rectal nerve, and the perineal nerve [6]. The
dorsal nerve of the penis is primarily a sensory
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