waterhouse urethroplasty

Male urethral stricture is a common disease in urology, which can be divided into three categories according to its etiology, congenital, inflammatory and traumatic. Congenital urethral stricture is less common, such as congenital urethral stricture, urethral valve, fine hypertrophy, urethral lumen narrowing. Inflammatory urethral stricture is caused by a specific or non-specific urinary tract infection. In specific infections, gonorrhea urethral stricture is more common; in non-specific infections, the urethral orifice and penile urethral stricture are common due to repeated foreskin and penile head inflammation, and the inflammatory urethra is caused by improper placement of the catheter. Stenosis has attracted widespread attention. This type of stenosis is more common in the corpus cavernosum. The traumatic urethral stricture is the most common acquired urethral stricture. The stenosis depends on the injury site. Most of the causes are in the urethra of the ball. In patients with pelvic fractures, located in the urethra of the membrane or at the tip of the prostate, the stenosis is generally not long, but the scar is hard. Severe urethral stricture can cause upper urinary tract water and renal dysfunction. There is often inflammation in the proximal and surrounding tissues of the urethral stricture. In some cases, inflammation around the urethra, abscess around the urethra, and even scrotal perineum can be worn. The formation of long-term unhealed urethra fistula, often complicated by urinary tract and reproductive tract infections, and some cases also have a suprapubic bladder stoma, should be prepared according to the specific circumstances. Those with narrower stenosis and less scars are expected to be cured by urethral dilatation. If the urethral dilatation fails or the effect is not good, other surgical treatment methods should be chosen. Endoscopic surgery for the treatment of urethral stricture has a positive effect, has been widely used in clinical, with small trauma, less bleeding, less postoperative complications, etc., should be the preferred method for the treatment of urethral stricture. However, it requires special equipment. For complicated urethral strictures, especially those with long stenosis, open surgical treatment is still the main means. Therefore, endovascular treatment can not completely replace other surgical treatments. The posterior urethra is located behind the pubic bone, and the perineal route is often poorly exposed, making the operation difficult. Excision of part of the pubic symphysis directly reveals the entire posterior urethra, satisfactorily solves the problem of poor exposure, so that the resection scar and the posterior urethral anastomosis can be performed under direct vision. Walker (1921) first performed a prostate cancer resection with a pubic symphysis. Pierce (1962) applied this approach for the first time in a patient with a pelvic fracture and a urethral stricture after urethral repair. In 1963, the Waterhouse system introduced the use of this approach for lower urinary tract surgery, including repair and anastomosis of the urethral stricture. Since then, the surgery has been named Waterhouse Urethuoplasty. Treatment of diseases: urethral stricture Indication The advantages of waterhouse urethroplasty are that it is well exposed, can remove scars and anastomosis of the urethra under direct vision, so it is especially suitable for cases where multiple surgical failures, severe perineal scars, and long posterior urethral stricture. There was no significant effect on weight after this operation. However, due to the need to open or remove part of the pubic bone, the operation is more complicated. In addition, intraoperative damage to the prostate venous plexus and the infraorbital venous plexus caused by massive bleeding, and some postoperative stress urinary incontinence. The development of intracavitary techniques has enabled the treatment of many high posterior urethral strictures. Therefore, this surgical approach is only suitable for a very small number of cases and should not be used as a routine method for posterior urethral anastomosis. Preoperative preparation 1. Pay attention to the degree of adhesion and adhesion of the urethral stricture and the rectum. If the adhesion is heavier or wider, the possibility of injury to the rectum should be fully estimated. The operation should be performed before the operation. 2. Patients with suprapubic bladder stoma should wash the bladder repeatedly before surgery. Urine bacterial culture examination. 3. Strengthen antibiotic treatment 2 to 3 days before surgery to prevent postoperative infection. 4. Prepare for blood transfusion. Surgical procedure Incision The inferior midline incision, the lower edge of the penis extends into the "human" shape. 2. Reveal the pubic symphysis The abdominal incision cuts the layers in turn until the anterior bladder space. The incision at the base of the pubic penis is cut to the surface of the pubic symphysis and is bluntly free along the surface. The penile suspensory ligament and the superficial vein of the penis are cut at the lower edge of the pubic symphysis, so that the root of the penis is displaced forward and downward, and a distance can exist between the root of the penis and the lower edge of the pubic symphysis. 3. Free pubic symphysis The finger is inserted into the posterior pubic space, and the anterior wall of the bladder is bluntly released along the periosteal surface behind the pubic symphysis until the prostate surface and the prostate tip. Use a large right angle clamp to close the periosteum of the lower edge of the pubic bone through the urogenital sputum, so that the tip of the nipple merges with the finger that extends into the pubic bone, and close the puberal periosteum to cut the urogenital ridge from both sides, so that the pubic symphysis is released. 4cm width. 4. Excision of partial pubic symphy Cut the pubic periosteum on the pubic symphysis and dissociate it with the pubis, to the left and right 2 to 3 cm, lead the wire saw, respectively, cut the pubic bone 2 cm from the midline, remove the removed pubis, and stop the bleeding with bone wax. . 5. Resection of the scar of the urethra scar After removing the removed pubis, the urethral scar can be seen directly under the urethral scar. A thick urethral probe is inserted into the posterior urethra via a bladder stoma or a bladder incision so that its tip reaches the proximal end of the urethra at the stenosis. Insert the urethral probe from the urethral opening to the distal end of the stenosis. Under the guidance of the probe, carefully detach and remove the narrow segment of the scar to expose the normal urethral rupture. 6. Anastomosis After a slight release of the urethral stumps on both sides, the end of the urethra was anastomosed with a 3-0 absorbable line. When anastomosis, a catheter of F16-18 is reserved in the urethra as a stent. If the urethral stricture is longer, and the pubic symphysis incision can not free the urethra, the surgical procedure should be performed according to the perineal perineal posterior urethral anastomosis. The perineal incision is used to expose the urethra, the scar is removed, and the free urethra is broken. Ready to match. In order to ensure that the anastomosis is carried out under no tension, the two corpus cavernosums can be cut open and the edges sutured to stop bleeding. After the urethral anastomosis is performed, the urethra of the ball is located between the two corpus cavernosums, and the straightening is straight, and the anastomosis can be tension-free. 7. Close the incision and place the drainage A catheter was placed in the urethra, a vaginal bladder stoma was performed, the pubic periosteum was sutured, and a rubber tube was drained from the posterior pubis. The perineal incision was placed with a rubber sheet to drain, and the incision was closed layer by layer.