Transmeatal Urethral Surgery: Anterior Urethral Strictures—Techniques and Early Outcomes

Introduction: Urethral strictures affect about 1% of men over 65 in the United States and significantly impact quality of life. 1 Most strictures (92.2%) occur anteriorly. 2 Urethroplasty, the gold standard treatment, is traditionally open but can be performed endoscopically with comparable results. This prospective study describes a technique for transmeatal urethral surgery with buccal graft urethroplasty for anterior urethral strictures. Methods: A 21 French direct vision internal urethrotomy (DVIU) cystoscope is used to inspect the stricture and make an incision along its ventral aspect. After the stricture is measured, a graft of buccal mucosa is harvested. For graft deployment, we utilize a 26 French Wolf Offset Nephroscope™ and a rigid injeTAK® cystoscopy needle. At the distal aspect of the urethrotomy, the needle is passed through the urethra and out the perineum. A pair of the sutures is placed on either side of the urethrotomy and held externally at the meatus. The graft is oriented with the lamina propria facing the spongiosum. The previously placed sutures are then passed from lamina propria to mucosa at the distal aspect of the graft. The sutures are tied, creating a knot on the mucosal side. The external sutures are then pulled, and the graft retracts into the urethra. The JNW Urtract™ and Securestrap® are then used for graft fixation. Graft Deployment: At the distal aspect of the urethrotomy, the injeTAK® needle is passed through the urethra and out of the perineum. A pair of the sutures is then placed on either side of the urethrotomy. These are held in place at the meatus to maintain proper laterality and avoid twisting. The graft is oriented into position, with the anti-mucosa facing the exposed spongiosum and the mucosa facing the lumen. The previously placed sutures are then passed from anti-mucosa to mucosa using a free Mayo needle at the distal aspect of the graft. The suture pairs are tied, creating a knot on the mucosal side. The external sutures are then pulled, and the graft retracts into the urethra. Cystoscopy is performed to ensure the graft is covering the urethrotomy. Graft Fixation: The JNW Urtract was then introduced with the Securestrap® (a Vicryl tacking suture). While a finger externally compresses the perineum toward the tip of the Securestrap®, the ventral midline portion of the graft is secured. A 22 French Foley catheter is then placed over a wire. Results: Out of 20 total patients, 13 are eligible for their 4-month follow-up. Of those who have completed follow-up, 86% had urethral patency on cystoscopy. The average duration of foley catheterization was 2.4 weeks. The average operative time was 100.8 minutes, and the average estimated blood loss was 37.5 cc. Conclusion: Transmeatal urethral surgery is a safe and effective repair option for management of anterior urethral stricture disease. The authors have no disclosures or commercial associations that might create a conflict of interest. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Data and video obtained during the treatment of patients at Mayo Clinic in Rochester, Minnesota. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. No conflicts of interest or obligations resulted from data collection. Runtime of video: 8 mins 52 secs.