Perineal Urethrostomy

  • Introduction
  • Lectures
  • Articles
  • F.A.Q.
  • Results
  • Questionnaire
  • Surgical Techniques
The surgical technique of “Perineal urethrostomy” is to create a new urethral opening via the perineum, just above the anus (figure 1), thus avoiding that urine need to travel through the entire length of the urethra (figure 2). Using this technique the male urethra, 12-18 cm long, becomes similar to the female urethra, 5-6 cm long. This change permits that the bladder requires a shorter tract to push out urine.

foto-1

figure 1

foto-2

figure 2

The surgical technique of Perineal urethrostomy does not interfere with urinary continence and does not require the use of external pads or catheter. The patient is requested to void in a seated position because urinary flow is through the perineal opening and no longer through the apex of the glans. This perineal opening is concealed (figures 3 – 4) and is not visible when the patient is in a standing position.

foto3A

figure 3

foto3B

figure 4

The surgical technique of Perineal urethrostomy is basically suggested in the following cases:

  • Patients with urethral strictures associated with superficial bladder tumor which requires periodical cystoscopy or endoscopic removal of the tumor. By using the perineal opening, it is easy for the urologist to perform any endoscopic procedure. For the patient, this procedure is painless.
  • Patients with urethral strictures associated with neurogenic bladder, bladder diverticula, showing high post-voiding residual urine volume. Since the urethra is shorter after the procedure, it is easier to obtain a complete emptying of the bladder.
  • Patients with urethral strictures who had undergone previous and numerous failed surgical attempts to repair urethral stricture disease, showing a high risk of stricture recurrence rate.
  • Elderly patients with urethral strictures associated with poor general health conditions in which an extended time under anesthesia in order to perform complex urethral repair is not suggested.
Lecture n° 1:

Uretroplastia en dos tiempos ¿cómo y cuándo ?
51 Curso de Urologia Fundació Puigevert
18 – 20 de octubre 2006
Barcelona – Spain

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Article n° 1
Peterson AC, Palminteri E, Lazzeri M, Guanzoni G, Barbagli G, Webster GD.
Heroic measures may not always be justified in extensive urethral stricture due to lichen sclerosus (balanitis xerotica obliterans).
Urology. 2004 Sep;64(3):565-8.

OBJECTIVES: Strictures due to lichen sclerosus (LS) may affect the urethra as far proximally as the mid-bulb. For such strictures, a staged full-length repair is required and should use a nonpenile graft source such as buccal mucosa. Many cases occur in a population already accustomed to seated voiding, leading us to re-evaluate this approach and, in some circumstances, recommend definitive perineal urethrostomy alone.
METHODS:We reviewed the medical records and retrograde urethrograms of all patients undergoing surgery for LS at our facilities between January 1991 and June 2002.
RESULTS: A total of 63 patients, with an average age of 54.2 years, underwent surgery for LS stricture with an average follow-up of 38.5 months (range 4 to 117). Of the 63 patients, 19 underwent grafting in preparation for future reconstruction. Of these, 11 completed the second-stage repair, and 8 patients elected not to undergo the second stage of the repair, leaving a functional perineal urethrostomy. This led us to look more critically at definitive perineal urethrostomy alone for some patients. Parallel with the staged repairs, and subsequent to them, 44 patients underwent perineal urethrostomy alone.
CONCLUSIONS: The often extensive nature of LS, the prevailing philosophy that urethroplasty must use nonpenile skin, the limited availability of such sources, and the acceptance of many patients for seated voiding makes definitive perineal urethrostomy alone a viable treatment option. In all our cases, this satisfied patients’ quality of life concerns, leaving the anterior urethra dry and amenable to future repair. Younger men desirous of penile voiding should still be considered for staged repair using current techniques.

Article n° 2

Guido Barbagli, Michele De Angelis, Giuseppe Romano and Massimo Lazzeri
Clinical outcome and quality of life assessment in patients treated with perineal urethrostomy for anterior urethral stricture disease
J Urol, 2009: 182, 548-557

Purpose: We performed a quality of life assessment for patients treated with perineal urethrostomy for anterior urethral stricture disease.

Material and methods: We retrospectively reviewed 173 patients (median age 55 years) who underwent perineal urethrostomy (from 1978 to 2007) as part of a plan for a staged urethroplasty repair for a complex anterior urethral stricture. The perineostomy was made using flap urethroplasty. The clinical outcome was considered a failure when postoperative instrumentation was needed. A questionnaire was used to evaluate patient quality of life and satisfaction.

Results: Stricture etiology was unknown in 50.3% of the cases, lichen sclerosus in 17.3%, catheter in 13.3%, instrumentation in 8.7%, failed hypospadias repair in 4.6%, trauma in 4.1% and infection in 1.7%. Stricture length was 1 to less than 2 cm in 1.2% of cases, 2 to less than 3 cm in 3.5%, 3 to less than 4 cm in 12.1%, 4 to less than 5 cm in 13.8%, 5 to less than 6 cm in 7.5%, greater than 6 cm in 4.1% and panurethral in 57.8%. Of 173 patients 91 (52.6%) underwent prior urethroplasty. Median follow-up length was 62 months (range 12 to 361). Of 173 cases 121 (70%) were successful and 52 (30%) were failure, requiring revision of the perineostomy. Of 173 patients 135 (78%) were satisfied with the results obtained with surgery, 33 (19.1%) were very satisfied, 127 (73.4%) with a median age of 57 years (range 23 to 85) refused to do the second stage of urethroplasty and 46 (26.6%) with a median age of 47.5 years (range 27 to 72) are currently on a waiting list for the second stage of urethroplasty.

Conclusion: Perineostomy is a necessary procedure for patients with complex urethral pathology and satisfaction rates are higt.

1. Question: Can the surgical procedure be performed with full coverage by the National Health Care System?
Answer: Yes.


2. Question: What kind of anesthesia is used for this surgery?
Answer: General anesthesia with oro-tracheal intubation.


3. Question: How many hours does the surgery take?
Answer: About 2 hours.


4. Question: Are there any risks concerning erection, fertility and urinary incontinence after the surgery?
Answer: No, there aren’t.


5. Question: How many days of hospital recovery are expected following the surgery?
Answer: In general, from 5 to 7 days.


6. Question: How long will I have to use a catheter after the surgery?
Answer: The urethral catheter must stay in place for two weeks after the surgery.


7. Question: Are there any particular recommendations during convalescence?
Answer: During convalescence, the use antibiotics until the catheter is removed is suggested. Avoiding long car trips, as well as heavy labor and sexual and sports activities are also suggested.


8. Question: When will I be able to resume my working, sexual and sports activities?
Answer: All these activities can be gradually resumed about 30 days after the removal of the catheter.


9. Question: Can I ride a bike or a motorcycle immediately after the surgery?
Answer: It is not recommended to ride bikes, motorcycles or horses after the surgery.


10. Question: What kinds of foods and drinks should be avoided after the surgery?
Answer: Beer and sparkling wines should be avoided, as well as large quantities of chocolate, cocoa, nuts and shellfish.

QUESTIONNAIRE ON PATIENT QUALITY OF LIFE AFTER PERINEAL URETHROSTOMY

Results on 173 patients
Barbagli G. et al, J Urol 2009: 182, 548 – 557


Has the perineal urethrostomy caused you any problems?

questionario-en01 Yes 16%
No 84%

If you answered Yes:

questionario-en02 Psychological problems 32%
Urination problems 46%
Sexual activity problems 22%

Have you had problems with your partner due to this operation?

questionario-en03 Yes 18%
No 82%

If you answered Yes:

questionario-en04 Psychological problems 35%
Penetration problems 40%
Minor problems 25%

Are you pleased with the results obtained with surgery?

questionario-en05 Dissatisfied 1.2%
A little satisfied 1.7%
Satisfied 78%
Very satisfied 19.1%

How would you evaluate these results?

questionario-en06 Negative 1.7%
Fair/passable 2.3%
Good 69.9%
Excellent 26.1%

Would you undergo this type of operation again?

questionario-en07 Yes 97.1%
No 2.9%

Would you like to undergo second stage urethroplasty to restore normal urinary function?

questionario-en08 Yes 26.6%
No 73.4%