Adult & Pediatric Urology
4th Edition

For the purpose of this discussion, the pendulous urethra describes that portion between the glans meatus and the suspensory ligament of the penis, at which point the bulbar urethra commences. Strictures in this location may result from proximal extension of BXO, from infection, or from catheter or instrument trauma; in the latter event, they are usually short and located at the penoscrotal junction somewhat opposite the suspensory ligament of the penis. Although very accessible to dilation or urethrotomy management, these techniques do not tend to be curative for reasons discussed previously. The cause of penile urethral strictures have changed in recent years, with those caused by BXO making up a higher proportion, in part as a result of more frequent recognition of the condition. BXO is the genital form of lichen sclerosis, and this may be the preferred terminology to bring us in line with dermatology and gynecology (73). In the male, it is a frequent cause of phimosis and, in the majority of cases, circumcision is curative. However, it may involve the urethra locally or extensively (80).
Anastomotic urethroplasty generally is inappropriate in this location because excision and spatulated reanastomosis of even the shortest penile urethral stricture will incur at least 1 cm of urethral shortening, which is sufficient to cause ventral chordee. Hence, anastomotic repairs should be reserved for the patient in whom sexual function is no longer a consideration. Substitution repairs employ either graft or flap. Full-thickness skin graft repairs in the pendulous urethra may use either preputial or extragenital skin and carry good results. They may be used as onlays to augment the strictured urethral lumen, and almost never should be used as a full-circumference urethral replacement. Graft take is good, and cosmetic resurfacing of the penile shaft can be accomplished using penile skin or a local scrotal skin flap. Recently, Barbagli and associates (6,7) have described a dorsal graft technique, with the graft bed being the undersurface of the adjacent corporal body. Full-thickness skin graft repairs generally maintain their caliber well (other than the approximately 20% expected graft shrinkage); however, they appear to exhibit poor longitudinal elasticity and hence have a tendency to produce ventral penile chordee, a major consideration when this repair is used in the sexually active male. This problem is more apparent when full-circumference or long skin-graft repairs are used.
For the aforementioned reasons, the optimal management for the one-stage repair of pendulous urethral strictures appears to be the use of a pedicled island of penile skin, generally as an onlay. A number of variations of the operation have been reported by Orandi (69), Quartey (74), Turner-Warwick (85), and Mundy and Stephenson (59). In the uncircumcised male, a pedicled island of foreskin may be used with excellent cosmetic outcome, also allowing the use of the moisture-resistant inner face skin to an advantage. Even after circumcision, there is invariably sufficient penile shaft skin to allow the island to be fashioned with its long axis along the shaft of the penis and with its pedicle based laterally (i.e., laterally pedicled island of penile skin). As mentioned previously, McAninch (52) has described such a repair with the skin island based on a fasciocutaneous rather than a subcutaneous vascular pedicle, improving its vascularity; he has used this technique to repair long strictures. In these circumstances, the skin island has been a distal penile circumferential island obtained by parallel circumcising incisions.
Most commonly, the island of skin is used as an onlay to increase urethral caliber at the stricture site (Fig. 36.10 and Fig. 36.11). The appropriately sized and shaped island skin is sutured to a roof strip of “native” strictured urethra and two-layer cover is achieved, trying to avoid overlapping suture lines. A small stenting catheter is used, and its removal approximately 14 days later is preceded by a pericatheter urethrogram. Postoperative dressings should be supportive and not constrictive, and when necessary, a microsuction drain may be placed along the shaft beneath the skin closure flap. The width of the pedicled island should be sufficient to create a urethra of at least 25 Fr. In practice, allowing for a small amount of shrinkage, and accepting that the native urethral roof strip adds some to the circumference, the island of skin needs to be between 2 and 3 cm in width. In the event the penile urethral stricture extends into the fossa navicularis, the distal part of the flap should be tunneled into the glans after the meatus, and the glandular urethra have been incised on the ventral surface. The flap then resurfaces the created glans cleft, with the tip of the flap being sutured to the edges of the glans at the meatus. This maintains the normal glans appearance and also avoids retrusion of the meatus. In the event the stricture extends into the scrotal urethra, the skin island needs to be planned inventively to avoid the use of hair-bearing penoscrotal skin. This usually is accomplished by raising the skin island along the ventral shaft of the penis at the required width and proximally coursing the island around the distal shaft of the penis in a circumcising fashion. In this manner, “J” flaps with lengths of up to 15 cm can be obtained, and in most, primary, tension-free skin closure is possible. In the event penile skin cover is not possible, a rotation flap of scrotal skin can be mobilized from the anterior scrotum to resurface the ventral shaft of the penis. Although hair-bearing, its ventral location will render it unobtrusive, and of course, epilation is a possibility.
FIGURE 36.10. Onlay urethroplasty of a pendulous urethral stricture (Orandi repair). A: The stricture is approached through a ventral penile incision. The outline of the skin island to be used for onlay is marked once the stricture has been opened and its length and caliber determined (B and C). The skin island is raised on a subcutaneous vascular pedicle (C). The skin island is rotated inward and sutured as an onlay to augment urethral caliber (D and E). Skin closure is in at least two layers to avoid fistula formation (F).
FIGURE 36.11. A: A long, tight pendulous urethral stricture. B: The same patient following tube replacement of the strictured urethra using a laterally pedicled island of penile skin. The island of skin was obtained in the vertical axis of the penis, and penile skin closure was accomplished primarily.
Staged repair of the pendulous urethra is necessary in complicated cases, including patients who have had multiple

prior procedures where there is considerable local scarring and skin shortage, where onlay of a flap is not possible, or where BXO is the cause. In the latter circumstances, a full-thickness graft from an extragenital source will be introduced to resurface the ventral penis after the strictured portion of the urethra has been excised. This source may be either buccal graft or postauricular skin, or combinations of the two when the extent of the replacement is extensive. Interim revision of the proximal urethrostomy may be required if there is any evidence of narrowing. At the second stage, at least 6 months later, the neourethra is tubularized from the graft, with the native penile skin being used to resurface the penis. Although simple in concept, this repair relies on full-thickness graft take on the ventral shaft of the penis, and this is not always predictable. The recent introduction of buccal mucosa has lead to renewed interest in the free grafts in the anterior urethra. As previously mentioned, buccal mucosa is easy to harvest from either the inner cheek or the lip. Some prefer to infiltrate with 1 in 100,000 epinephrine to aid the dissection, and an ellipsoid incision is made avoiding the salivary duct. Even without epinephrine bleeding is minimal, and the graft dimensions may be as high as 3 cm × 6 cm at the largest axis. Discomfort or problems with the donor site are minimal and large grafts can be taken. The graft take with buccal mucosa has been excellent thus far, but results are still very short term.