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This article introduces a surgical method using a pedicled tunica vaginalis to treat long-segment urethral stricture resulting from lichen sclerosus. The tunica vaginalis is an excellent substitute for the urethra, leading to quick postoperative recovery for patients.
Urethroplasty for the management of long-segment urethral strictures associated with lichen sclerosus presents considerable clinical challenges. Oral mucosal grafts are commonly employed but are vulnerable to posttransplantation infection and recurrent stricture formation. Furthermore, the necessity for anesthesia and oral graft harvesting restricts their application in primary healthcare settings.
The single layer of flattened epithelium of the tunica vaginalis can serve as a potential alternative to oral mucosa. Animal experiments have demonstrated that the tunica vaginalis can readily form a tight connection with the multilayered urothelium of the urethra. Utilizing the tunica vaginalis as a scaffold for urethral re-epithelialization may help reduce the risk of recurrence of urethral stricture after surgery. Over a 19 year period, pedicled tunica vaginalis urethroplasty has been used for successfully treating 86 cases.
The surgical procedure involves dorsally incising the urethral stricture segment, then covering it with a pedicled tunica vaginalis patch followed by suturing. Postoperatively, the pedicled tunica vaginalis graft exhibits good vascularization and take rate, facilitating urethral re-epithelialization. The surgical procedure is conducted in a sterile environment to mitigate the potential for infectious complications. Moreover, the operation can be executed under spinal anesthesia, which facilitates its implementation in primary healthcare settings.
Lichen sclerosus (LS) of the penis is a chronic inflammatory dermatological condition mediated by lymphocytes, and it is considered an acquired dermatosis1. Hallmark symptoms of LS of the penis include chronic inflammation of the glans penis, abnormal dryness in the appearance of the affected skin, and endarteritis in the subcutaneous arteries supplying the glans penis2. Most patients with LS of the penis have a history of phimosis, with lesions primarily occurring on the foreskin, glans penis, external urethral meatus, or anterior urethra. Some patients may be asymptomatic throughout the disease course, while others can experience foreskin and glans adhesions leading to phimosis and voiding difficulties due to urethral lesions3. The peak incidence of LS occurs in the age groups of 30-49 years and 8-10 years4. Clinical manifestations of LS are variable. In the early stages of the disease, symptoms can be inconspicuous. Initial changes may include milky-white plaques, recurrent ulcers, or purulent discharge on the inner foreskin and glans, accompanied by itching, stinging, and burning sensations.
As LS progresses, decreased elasticity of skin and mucosa develops due to atrophic changes of the foreskin and glans, which can negatively impact sexual function. As the LS further progresses, the external urethral meatus may become stenotic owing to LS invasion, and even long segment anterior urethral stricture may form with the proximal extension of lesions. However, LS involvement of the anterior urethra generally stops with the urethra bulbar and is rarely seen in the membranous and prostatic segments1. Severe urethral stricture can result in increased postvoid residual urine, upper tract hydronephrosis, or renal damage. In urethroplasty for long-segment anterior urethral stricture caused by LS, grafts are usually required to be implanted in the urethra.
Long-segment anterior urethral strictures, defined as strictures exceeding 2 cm in length within the anterior urethra, pose a significant clinical challenge in management and often necessitate the utilization of grafts or substitutes to repair the urethral defect-a procedure known as urethroplasty5. Among the commonly employed urethral substitutes are bladder mucosa6, oral mucosa7, colonic mucosa8, preputial graft9, and tunica vaginalis10, each possessing unique advantages and limitations.
The tunica vaginalis, an extension of the peritoneum, has exhibited promising outcomes in both preclinical animal models and clinical trials as a substitute material for urethral reconstruction11,12,13,14. Its mesothelial nature confers an intrinsic ability to mitigate scar tissue formation. Experimental evidence from animal studies15 has indicated that the single layer of flattened epithelial cells comprising the tunica vaginalis readily establishes a tight junctional interface with the multilayered epithelial cells of the urethral mucosa.
Here, we utilized the technique of transplanting a pedicled tunica vaginalis patch to address long-segment anterior urethral strictures caused by lichen sclerosus of the glans penis (Figure 1). From August 2004 to April 2023, 86 cases were successfully completed, yielding satisfactory postoperative outcomes. This surgical approach offers a novel and effective treatment modality for patients with long-segment anterior urethral strictures caused by lichen sclerosus of the glans penis.
It overcomes the limitations associated with other surgical techniques, boasting a high success rate, convenient material sourcing, simplicity of execution, minimal invasiveness, and a reduced incidence of complications13.
However, long-segment anterior urethral stricture caused by lichen sclerosus of the glans penis is not very commonly employed worldwide, and the literature on the subject is not abundant16. Yet it warrants implementation in medical institutions at all levels, particularly at grassroots facilities, as an ideal method for treating long-segment anterior urethral strictures.
The study cohort comprised 86 male patients aged between 20 and 66 years, with a mean age of 40. Each patient received a single-stage tunica vaginalis graft, with 70 cases involving a unilateral tunica vaginalis graft and 16 cases involving a bilateral tunica vaginalis graft. The patients provided informed consent to use and publish their data.
1. Preoperative preparation
Ensure that patients with concurrent urethral infection undergo preoperative cystostomy first. Examine urinary bacterial cultures according to the drug sensitivity results and then, use antibiotics to which the bacteria are sensitive to treat them for 2-3 weeks before surgery. Perform the surgery after the urethral infections are sufficiently under control.
2. Surgical positioning of patients
NOTE: The surgical positioning must vary according to the location of the urethral stricture in each patient.
3. Surgical procedure
4. Special cases
5. Postoperative care
See Supplemental Table S1 for patients' clinical history and preoperative measures. Preoperatively, all 86 patients underwent retrograde urethrography and uroflowmetry examinations. Each patient received a single-stage tunica vaginalis graft, with 70 cases involving a unilateral tunica vaginalis graft and 16 cases involving a bilateral tunica vaginalis graft. Postoperative follow-up ranged from 6 to 48 months, with a mean of 24 months. Among these individuals, 84 exhibited unimp...
Numerous urological researchers have investigated a diverse range of graft materials for urethral reconstruction, including genital and extragenital flaps or free grafts17. These materials include preputial graft, bladder mucosa, oral mucosa, tunica vaginalis, and colonic mucosa.
Oral mucosal grafts have achieved high success rates for the treatment of anterior urethral strictures caused by LS, with Xu et al. reporting a success rate of 88.9%18. ...
None of the authors have any conflicts of interest to declare.
In the writing process of this manuscript, the authors utilized the Claude language model developed by Anthropic AI as an assistive tool for grammar checking and correction. Claude provided valuable feedback and suggestions, but the final content was thoroughly reviewed and verified by the authors to ensure accuracy and originality. The authors take full responsibility for the content and views expressed in this manuscript.
Name | Company | Catalog Number | Comments |
2-0/T non-absorbable suture | Ethicon Inc | SA845G | Sterile, radiation sterilization, disposable |
22F silicone catheter | UROVISION | G2219043 | A disposable Foley Catheter |
3-0 non-absorbable suture | Ethicon Inc | SA84G | Sterile, radiation sterilization, disposable |
5-0 absorbable suture | Ethicon Inc | VCP1433 | Sterile, radiation sterilization, disposable |
Digital X-ray Radiography Fluoroscopy System | Beijing Shimadzu Madical Equipment Co.,Ltd | ZS-200 | Retrograde urethrograms use |
Iohexol Injection | STARRY PHARMACEUTICAL | H20203258 | Sterile, disposable,Retrograde urethrograms use |
SPSS 20.0 | statistical software | ||
Urodynamic Analyzer | WBL MEDICAL | Nidoc 970A | Maximum flow rate detection |
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