Modern Reinterpretation of Scrotal Drop Back Procedure for Bulbar Urethral Loss: Surgical Insights

Abstract

Clinical History, Physical Examination, Diagnosis, Intervention, Follow-Up/Outcomes. We present the case of a 53-year-old gentleman who had a road traffic accident after which he developed painful acute urinary retention along with pelvic fracture. He was found to have a pelvic fracture urethral injury and suprapubic catheter (SPC) was placed. He was evaluated with retrograde urethrogram (RGU) and micturating cystourethrogram (MCU) to know the site and extent of urethral injury/defect. The findings were suggestive of 1.6 cm focal distraction defect at bulbomembranous junction with right pubic bone fracture. He was managed with progressive single-stage anastomotic urethroplasty. Postoperative course was uneventful and he was discharged with both per-urethral catheter (PUC) and SPC in situ. PUC was removed after 1 month after which he voided effectively and satisfactorily. SPC was removed after 1 week of removing PUC. He presented again after 1 month of SPC removal with complaints of poor urinary flow. Urethroscopy was done, which was suggestive of anastomotic site stricture, after which endoscopic dilatation was done up to 22F and PUC was reinserted. PUC was removed after 7 days. Voiding difficulty was persistent even after endoscopic dilatation and he went into acute urinary retention after 2 weeks of endoscopic dilatation, hence SPC was placed again and he was referred to us for further management. After detailed history of antecedent events, he was examined. General physical examination was normal. On per abdomen examination, there was 16F SPC in situ with normal other parameters. On local examination there was a midline perineal scar of previous surgery. Rest of the systemic examinations were normal. We reinvestigated him. RGU and MCU was done and it was found that there was a defect of 7.74 cm from penobulbar junction to membranous urethra probably caused by bulbar ischemia. Managing this ischemic condition necessitates vascularized flaps, either circumferentially substituting the loss or augmenting in cases of stenosis. Options encompass a preputial tube on a vascular pedicle mobilized subcutaneously to the perineum, an innovative technique employing oral mucosal flap urethroplasty, dorsal buccal mucosal graft with a ventral pedicle preputial flap, a pedicled preputial or penile skin flap, and entero-urethroplasty utilizing retubularized sigmoid colon along with its associated mesentery. Post-use of the preputial tube, patients rarely achieve normal voiding streams. The preputial tube serves as a conduit but lacks the viscoelastic properties of a normal urethra. Flap surgeries for bulbar urethral strictures offer potential advantages but have several notable disadvantages. First, these procedures are characterized by their complexity and the need for specialized expertise, limiting the pool of surgeons proficiently performing them. In addition, the intricate nature of flap surgeries often leads to extended operating times, which can increase the risk of complications and patient discomfort. Second, flap failure is a significant concern, as the success of these surgeries hinges on the viability of transplanted tissue. Factors such as poor blood supply, infection, or healing issues can lead to graft failure, necessitating further interventions. Moreover, using donor sites for tissue extraction can result in donor site morbidity, adding to patient discomfort and extending the recovery period. Finally, the resource-intensive nature of flap surgeries, involving specialized equipment, prolonged hospital stays, and meticulous postoperative care, can significantly escalate healthcare costs. In light of these drawbacks, alternative approaches such as the scrotal drop back surgery should be considered, offering a more straightforward solution that may mitigate some of these challenges while effectively addressing bulbar urethral necrosis. Addressing high-lying urethral strictures through surgical intervention presents considerable challenges. Multiple procedures are often necessary for many strictures, particularly traumatic ones linked with severe pelvic fractures, to achieve lasting freedom from recurrence. What sets scrotal drop back apart is its simplified approach—it does not require intricate flap knowledge or the complexities associated with harvesting and transferring vascularized tissue. This relative simplicity can lead to shorter operating times, decreased surgical complications, and quicker postoperative recovery. The Turner-Warwick urethroplasty boasts two distinctive attributes well-suited for addressing deep strictures. First, the short yet wide funnel enables repeated inspections of the inlay up to and beyond the verumontanum. Second, the well-vascularized scrotal graft provides sufficient skin for necessary revisions without tension. This graft's visualizability and adjustability are crucial, as few repair methods for high-lying strictures assure universal freedom from recurrence. Hence our patient was taken up for Turner-Warwick stage one scrotal drop back procedure. Total duration of surgery was 190 minutes with around 100–150 mL of intraoperative blood loss. Postoperative period was uneventful. Drain was removed on postoperative day 2 and patient was discharged on postoperative day 5. PUC was removed after 6 weeks of surgery and SPC was removed 1 week thereafter. Patient voided effectively and satisfactorily. He was reassessed at 3 months and his urinary flow is good. He is planned for stage 2 of Turner-Warwick scrotal drop back surgery after 3 months (6 months from first surgery). Patients consent was obtained prior to the video recording for demonstration of the surgery and publication. No competing financial interests exists. Runtime of video: 6 mins 26 secs