Some Aspects of Urological Disease Among the Indigenous Peoples of

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					2326                                           S.A. MEDICAL JOURNAL                                        8 December 1973



    Some Aspects of Urological Disease Among the
      Indigenous Peoples of South West Mrica *
      PART H. MANAGEMENT OF COMPLICATED URETHRAL STRICTURES
           H. F. PIETERSE,      M.B. CH.B., M.MED. (CHill.), F.C.S. (S.A.),   Urological Service, State Hospitals,
                                                         Wil1dhoek, SWA

                           SUMMARY                                   The Johanson urethroplasty has, however, some impor-
                                                                  tant disadvantages. It is a multiple-stage procedure. In
  The Johanson type of urethroplasty is still the operatfon
                                                                  our experience it is often necessary to delay the second
  of choice in the majority of complicated urethral strictures.
                                                                  stage of the operation for 6 months or longer. Most
  It is relatively simple to perform and gives consistent         writers emphasize that there should be an interval of
  satisfactory results, provided that one insists upon an         at least 3 months between the first and second stages of
  adequate period of observation before proceeding to             the operation. Proximal or distal stomal stricture occur;;
  final urethral closure.                                         often, especially in cases with extensive periurethral fibro-
     The Johanson operation is, however, not suitable for         sis or chronic lymphoedema of the penis and scrotum.'
  membranobulbar strictures. A short review of the Turner-        The stomas must be regularly calibrated with urethral
  Warwick procedure is given. Proximal suturing of the            sounds and, with the least evidence of stenosis, it should
  scrotal flap can be extremely difficult. We have found a        be refashioned. Preferably a No. 28F sound should pass
  combined prostatectomy and scrotal flap urethroplasty           easily into the stomas. Revision is done by dividing the
  much easier to perform in some cases.                           strictured area and again suturing the skin edges to the
  S. Afr. Med. J., 47, 2326 (1973).                               mucosal edges. In cases of poor apposition of skin and
                                                                  mucous membrane, granulation tissue is apt to form
           JOHANSON URETHROPLASTY                                 which can usually be kept under control by light cauteri-
                                                                  zation.
There can be no doubt that the J ohanson type of ure-
 throplasty' is a boon to those of us who have to deal with                   LEADBETTER PROCEDURE
 large numbers of complicated urethral strictures. This
                                                                  In cases of high bulbar stricture we have used the Lead-
 procedure has many advantages. I[ is applicable to all types
                                                                  better technique,' whereby a large triangular skin flap is
 of strictures except very high bulbar or membranous
                                                                  fashioned alongside the marsupialized urethra. The bulb
strictures. It is capable of consistent performance by the
                                                                  is entirelv mobilized, the stricture area divided ventrally,
 average surgeon and does not depend upon either great
                                                                  and the distal tapered end of the skin flap sutured to the
technical accomplishment or great good fortune. Radical
                                                                  proximal edges of the urethrotomy.
en bloc excision of all fibrosed and granulomatous tissues,
sinuses and fistulae, can be practised without hesitation.
It is especially suitable for multiple strictures where a         Bladder Neck Contracture
full-length urethroplasty is needed from the tip of the              About 60°{, of our stricture cases also have a bladder
penis to the posterior urethra. In cases of either proxima!       neck contracture due to chronic sclerotic prostatitis. The
or distal stomal stenosis, the stoma can easily be refashion-     importance of a pre-operative voiding cysto-urethrogram
ed. No special or very expensive instruments are required.        in all cases has already been referred to in the Part I' of
   Basically, the first stage of the operation consists of        this article (Fig. I). When necessary' a transurethral resec-
a wide ventral urethrotomy, with excision of all scarred          tion of the bladder neck is easily done through the
and infected tissue, and marsupialization of the adjacent         proximal stoma at the first stage of the urethroplasty.
skin to the remaining strip of urethral roof. If the whole           Fernandes and Draper' reported that 80% of their
stricture is excised, a new urethral roof can be fashioned        cases required a transurethral resection of the prostate
by suturing the lateral skin flaps together in the midline.       for bladder neck contracture or prostatic hyperplasia.
The urethrotomy must extend into normal urethra proxi-            True prostatic hyperplasia is, however, exceptionally rare
mal and distal to the stricture. The proximal and distal          in our patients with complicated urethrS\1 strictures.
stomas are constructed by suturing skin to the circum-
ference of the urethral mucous membrane. After some
months, when urethrocutaneous epithelization is com-                TURNER· WARWICK URETHROPLASTY
pleted, the whole urethrotomy including the stomas, is            For very high bulbar or membranobulbar strictures, we
circumcised, leaving enough skin to suture without tension        ~ave  followed the technique as described by Turner-
over a 24F urethral catheter. The bulbar and cavernous            Warwick.'·- Only a brief description of this technique .will
tissues are mobilized, then the bulbar muscles, and then          be given. A primary midline incision is made into the
the skin. The tissues are closed in separate layers.              perineum and scrotum exposing the bulbar urethra which
'Date received: 27 June 1973.                                     is completely mobilized. The stricture is incised ventrally
8 Desember 1973                                          S.-A.   MEDIESE   TYDSKRIF                                         2327

                                                                       that the proximal apex of this incision will reach the
                                                                       proximal point of the opened urethra wit40ut tension.
                                                                       One thus has a bridge of scrotal skin between the 2
                                                                       incisions, which is inlayed into the floor of the opened
                                                                       urethra, reaching from the perineum to the verumonta-
                                                                       num, if necessary. The posterior apex of the scrotal in-
                                                                       cision is sutured to the posterior apex of the urethral
                                                                       incision. Distal to the membranous urethra the lateral
                                                                       margins of the scrotal incisions are sutured to the bulbar
                                                                       urethra by vertical mattress sutures (Fig. 2).
                                                                          If the stricture extends to, or involves, the membranous
                                                                       urethra, it should be dilated from 36F to 4OF. Dilatation
                                                                       of a tight membranous urethra results in an inverted
                                                                       V-shaped mucosal split extending to the verumontanum.
                                                                       The posterior apex of the scrotal incision is sutured to
                                                                       the proximal apex of this inverted V-shaped area just
                                                                       below the verumontanum and including a substantial bite
                                                                       of the underlying prostatic tissue.
                                                                          Suturing of the scrotal inlay proximal to the mem-
                                                                       branous urethra is exceedingly difficult without some
                                                                       special instruments. Turner-Warwick uses a special fully-
                                                                       curved Reverdin needle for insertion of the supramem-
                                                                       branous sutures, and a self-retaining type of long-bladed
                                                                       nasal speculum is used for exposure.
 Fig. 1. A retrograde urethrographic picture often seen.
 There is a membranobulbar stricture with fistulous tracts,
 a prostatogram due to ductasis of the prostatic ducts and                 COMBINED PROSTATECTOMY AND
 a bladder neck contracture.                                               SCROTAL FLAP URETHROPLASTY
                                                                       I! has already been emphasized that a large percentage
and at least 2 cm of normal urethra proximal and distal                of stricture cases have a bladder neck contracture which
to it. The scrotum is then pulled down to cover the                    also requires a bladder neck resection. To overcome the
primary incision with the result that the vertical incision            extreme difficulty of proximal suturing of the scrotal
now becomes horizont~1. The primary incision is approxi-               inlay graft in membranobulbar strictures we have tried
mated, apex to apex. The scrotal skin, now distal to the               the following technique in 10 patients. The first part of
horizontal closure, is invaginated into the proximal urethra           the operation is completed according to the Turner-War-
with the tip of the finger. A secondary vertical incision              wick procedure. A few long stay sutures are applied to
is then made in the midline of the scrotum in such a way               the proximal apex of the scrotal graft. The bladder is




                                                                                    Sc.<o\;O \ -;,,\o'j      fl",\,
                                                                                    f.":ed   te,   G';'i:'!0"al r1o.,?



                1>'-1\\ t.h<o4h col:.l-....tM        f'''''-\\
                 to   0r=   of   IOC.'ota.\   I;'\o'p-


                            Fig. 2. Combined Turner-Warwick scrotal inlay graft and prostatectomy.
2328                                        S.A.    MEDICAL          JOURNAL                                  8 December 1973

then opened suprapubically. The trigone is dissected from       mately 14 days or longer after urethral closure. To
the bladder neck to form a flap with the base below             maintain a catheter transurethrally causes the trapping of
the ureteric openings. The bladder neck is resected and         purulent exudate which may predispose to local break-
the prostatic tissue enucleated; it is usually very much        down ef the urethral closure, with subsequent fistulation
fibrosed and sharp scissor dissection is necessary. The         or sacculation.
apex of the scrotal graft is then pulled up into the              The treatment of complicated urethral strictures is
prostatic cavity by means of the stay sutures. It is            thus, in most cases, a protracted affair. One cannot help
sometimes more convenient to pass a Jacques catheter            becoming emotionally involved in the plight of some of
suprapubically through the prostatic cavity into the peri-      the cases. The il<ltural urge is to hurry along and do the
neal wound and suture the apex of the scrotal graft             second-stage urethral closure as soon as possible. A lot
around the distal end of the catheter, with the raw surface     of patience and fortitude is, h::Jwever, a prerequisite, and
outwards. The graft is then pulled up into the prostatic        this must be most carefully explained to the patient before
cavity by means of the catheter. The trigonal flap is           starting treatment. There can be no compromise. Recur-
pushed down into the prostatic cavity and sutured to the        rence of a stricture after closure of an urethra can
apex of the scrotal graft by taking substantial bites into      almost always be prevented by insisting upon an adequate
the underlying prostatic capsule. Great care should, how-       period of observation before proceeding to urethral clo-
ever, be taken that the rectal mucous membrane is not           sure. The period should always exceed 3 months and may.
perforated and included in these sutures; one might end         in the case of a diffi:::ult stricture, be more than 3 years.
up with a prostatorectal fistula, which is always a major
tragedy and very difficult to correct surgically.                       TOTALLY FROZEN PERINEUMS
   Lateral pressure is maintained on the graft by packing
the whole funnel-shaped cavity from below with a suitable       During the last 11 years we have had 24 cases in whom
gauze strip soaked in Hibitane solution. The urine is           the whole perineal area and scrotum were just one 'frozen'
drained suprapubically with a De Pezzer catheter. The           mass of scar tissue with multiple draining sinuses and
gauze packing is removed after 8 days.                          fistulas. In some cases there was also marked chronic
   Our results with this modification have been quite           lymphoedema of the penis, scro,um and the lower extremi-
satisfactory.   one of our cases became incontinent of          ties from chronic ilio-inguinal lymphadenitis. There were
urine after a combined prostatectomy and a scrotal flap         either multiple strictures or complete obliteration of the
urethroplasty as described above. Edwards et al.' reported      whole anterior urethra. Some patients were passing
in a recent article that 4 of 11 patients subjected to a        urine through several fistulae (watering-can perineum),
high scrotal flap urethroplasty had a prostatectomy done        but most of them were admitted with a complete urinary
in addition, and none became incontinent afterwards.            obstruction.
Possible reasons are discussed in their article.                   Because of the complete absence of any normal tissue
                                                                in the perineoscrotal ~;rea, we did not even contemplate
                                                                any form of local corrective surgery. Biopsies were always
   SECOND·STAGE URETHRAL CLOSURE                                done to exclude local tuberculosis or amoebiasis. Six of
                                                                these cases with watering-can perineums refused any
One of the disadvantages of any type of urethroplasty
                                                                form of operative intervention. Another 6 cases were
using either perineal or scrotal skin, is the inclusion of
                                                                quite satisfied with a suprapubic urinary drainage tube
hairs in the reconstructed urethra, especially if the closure
                                                                and left hospital. In 2 cases a urinary diversion by ileal
is somewhat sacculated. Residual hairs in the inlay be-
                                                                conduit was done. In our experience these patients find
come encrusted and lead to stone formation. We use a
                                                                it extremely difficult to cope with an ileostomy appliance.
fine needle inserted beside the hair and then by applying
                                                                especially those returning to the reserves and those who
a weak diathermy current, destroy the hair follicle. One
                                                                earn Cl living by heavy manual labour. We have, therefore.
is, however, rarely successful in doing a complete epilation.
                                                                been more inclined to do a ureterosigmoidostomy when
   The method of closure in all types of staged urethro-
                                                                the anal sphincter tone is satisfactory and there is no
plasties is basically the same. It should, preferably. be
                                                                perirectal or perianal involvement by sinuses or extensive
done over a 24F to 26F urethral sound. The urethrotomy
                                                                scar tissue formation. In 8 cases ureterosigmoidostomies
including the stomas is circumcised, leaving enough cir-
                                                                were done. In 4 cases a rectal bladder was fashioned by
cumferential skin for accurate apposition over the ure-
                                                                the usual technique. The rectosigmoid junction is tran-
thral sound. There is, however, still some controversy
                                                                sected, with closure of the distal stump. The ureters are
whether it should be a one-layer or a multiple-layer
                                                                then implanted distal to the stump. The proximal sigmoid
closure. We have tried the Browne closure: using steel
                                                                stump is then brought out as a permanent colostomy.
wire, glass beads and lead shot. We experienced a high
                                                                These 4 cases were willing to cope with a permanent
incidence of fistulatioll and diverticulum formation. We
                                                                colostomy, which is usually easier to take care of than an
have also tried a continuous nylon one-layer suture after       ileostomy.
mobilization of thick lateral flaps, but also found it                                     REFERENCES
unsatisfactory. The idea was to reduce the amount of            I. Johanson. B. (1953): Acta chir. scand., suppl.. p. 176.
tissue reaction caused by catgut. We have, however.             2. Leadbetter, G. W. jnr (1960): J. Urol.. 83, 54.
                                                                3. Pieterse, H. F. (1973): s. Afr. Med. J., 47, 2279.
reverted to the old technique of multiple-layer closure,        4. Fernandes, M. and Draper, J. W. (1969): Ibid., 101, 326.
sometimes with suction drainage. Perhaps the results will       ~. Turner-Warwick, R. T. (1960): Ibid., 83, 416.
                                                                6. Idem (1968): Ibid., 100, 303.
improve with the use of polyglycolic _suture material.          7. Edwards, L., Singh, M .. Natley, R. and Whitaker, R. (1972):   Brit.
                                                                   J. Urol., 44, 23.
   We always use suprapubic urinary diversion for approxi-      8. Browne. D. E. (1949): Proc. Ray. Soc. Med., 42, 466.

				
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