Revision of Perineal Urethrostomy Using a Meshed Split-Thickness Skin Graft
A 45-year-old male patient underwent partial penectomy and distal urethrostomy for erythroplasia of Queyrat (i.e. carcinoma in situ of squamous cell carcinoma) in 2008. Since he was extremely dissatisfied with the remaining penile stump, he consulted our center about the option of phallic reconstruction. On June 14, 2010, phallic reconstruction was performed. The native urethra was lengthened by means of a radial forearm free flap. The phallus was reconstructed with an anterolateral thigh flap. The urethra was positioned inside the phallus according to the ‘tube-in-a-tube’ principle. In October 2012, the patient presented with obstructive voiding symptoms. A diagnostic urethroscopy showed a suspicious lesion in the remaining native, bulbar urethra, and biopsy confirmed the recurrence of a poorly differentiated squamous cell carcinoma of the urethra. On December 13, 2012, he underwent excision of the remaining native, bulbar urethra with the creation of a perineal urethrostomy at the membranous urethra. The perineal urethrostomy was performed using the technique as described by Blandy et al. []. Unfortunately, the postoperative period was complicated by bleeding, wound dehiscence and infection (fig. ). Finally, the perineal urethrostomy became completely obliterated and a suprapubic catheter was placed (fig. ). As the patient accepted this only as a temporary solution, we proposed the revision of the perineal urethrostomy using a meshed split-thickness skin graft. This procedure was performed on April 23, 2013. The patient was placed in the lithotomy position and a midline perineal incision was made. Dissection was continued up to the level of the urogenital diaphragm. A flexible cystoscope was inserted along the suprapubic tract and brought through the bladder neck into the posterior urethra. This marked the place of obliteration as the light of the cystoscope could be seen through the perineal incision. The urethra was opened on the tip of the cystoscope. All fibrotic tissue was further excised until only healthy urethral mucosa remained. The urethral stump was spatulated over 1.5 cm. Vicryl 4.0 stay sutures were placed at the mucosa to facilitate identification and to prepare the anastomosis for the graft (fig. ). A split-thickness graft (10 × 15 cm) was harvested from the skin of the left thigh and meshed 1:1. In the middle of the graft, an opening was made to anastomose with the urethral opening. The edges of the graft were further tailored and anastomosed with the perineal skin edges. Several additional quilting sutures were placed to fix the graft against the perineal graft bed (fig. ). A compressive dressing and a 20-Fr urethral catheter were left in place for 5 days. After 5 days, the dressing was removed with satisfactory graft take. Subsequently, the catheter was also removed. At present (6 months of follow-up), the patient is voiding well. Maximum and average urinary flow are 22 and 13 ml/s, respectively. His International Prostate Symptom score is 5/35. The perineal wound has healed well, with minimal contraction of the grafted area (fig. ). Through the neomeatus, a 20-Fr catheter can be passed without any difficulties, indicating a sufficient diameter.\nThis study was approved of by the local ethics committee.