How to preserve the dorsal urethral plate during urethral surgery?

Preserving the Dorsal Urethral Plate During Urethral Surgery

The dorsal urethral plate should be preserved whenever possible during urethral reconstruction by using minimally invasive approaches that maintain its vascular supply, avoiding complete excision unless the tissue is diseased or unsuitable for reconstruction. 1, 2

Surgical Techniques for Urethral Plate Preservation

One-Sided Anterior Approach

• Perform a one-sided anterior dorsal onlay graft technique that preserves the lateral vascular supply to the urethra, the central tendon of the perineum, the bulbospongiosum muscle, and its perineal innervation. 2
• This approach achieved 92% success rates in patients with both bulbar and panurethral strictures with mean follow-up of 22 months. 2
• The technique minimizes tissue ischemia by avoiding complete urethral mobilization. 3

Muscle- and Nerve-Sparing Technique

• Avoid dissection of the bulbospongiosum muscle from the corpus spongiosum and leave the central tendon of the perineum intact during bulbar urethroplasty. 4
• This approach eliminates postvoiding dribbling and semen sequestration while maintaining excellent stricture-free outcomes. 4

Dorsal Inlay (Asopa) Technique

• Use the dorsal inlay technique when the urethral plate width is ≥1 cm after urethrotomy. 3
• Split the urethra ventrally to expose the stricture, then deepen the incision to include full thickness of the dorsal urethra. 3
• Fix grafts (preferably buccal mucosa) on the raw dorsal urethral surface with quilting sutures to anchor the graft. 3
• Retubularize the urethra in two layers with staggered suture lines. 3

When to Revise Rather Than Preserve

Focal Dense Strictures

• For focally dense strictures within longer segments, excise only the most severe portion with dorsal reapproximation to improve urethral plate quality. 1
• This allows simultaneous flap or graft onlay reconstruction while preserving the remaining plate. 1

Combined Tissue Transfer

• Combine multiple tissue transfer techniques to preserve the urethral plate in complex, long strictures (mean length 19 cm), achieving 88% excellent outcomes. 1
• Use fasciocutaneous flaps combined with buccal mucosa, bladder epithelium, or skin grafts for pan-urethral strictures. 1

Special Consideration: Lichen Sclerosus

When Preservation is Contraindicated

• In lichen sclerosus (LS), the urethral plate is often unusable and requires complete excision with staged reconstruction using nongenital tissue grafts. 5
• All 12 urethroplasties using genital skin flaps in LS patients failed, while only 1 of 16 patients using nongenital skin grafts failed at 3-year follow-up. 5

Early-Stage LS Management

• For short strictures early in LS disease, it may be reasonable to use flaps or onlay graft repairs to preserve buccal mucosa for potential complex repairs later. 5
• Use only nongenital skin or tissue grafts (buccal mucosa, bladder mucosa) in LS surgical management. 5

Glans-Preserving Approaches

Distal Urethral Strictures

• Perform reconstruction through a keyhole incision in the urethra for maximal exposure with minimal incision and glans preservation. 6
• After incising diseased dorsal urethral mucosa through the keyhole and meatus, perform a buccal mucosa graft pull-through resulting in dorsal inlay. 6
• This technique achieved complete resolution of complaints with significant flow rate improvement (Qmax from 4 to 24 mL/s) and excellent cosmetic results. 6

Critical Principles

Vascular Preservation

• Minimize ureteral devascularization during any surgical anastomosis to prevent ischemic complications. 5, 7
• Thorough knowledge of urethral vascular supply allows creative application of different tissue transfer techniques. 1

Avoiding Common Pitfalls

• Do not perform complete urethral mobilization when preservation techniques are feasible, as this increases tissue ischemia risk. 2, 3
• Avoid using genital skin in any form for LS-related strictures due to 90% recurrence rates. 5
• Ensure urethral plate width is adequate (≥1 cm) before attempting dorsal inlay techniques. 3