Introduction :

Urethroplasty means plastic surgery of the urethra. Herein we are going to describe urethroplasty in terms of; diagnosis, indications, surgical techniques and definition of failure or success. A lot of issues related to urethroplasty remain to be defined, therefore we will clarify the debatable issues and highlight the last advances on urethroplasty. There are two main causes which mandate urethroplasty; the first is the congenital anomalies with hypospadias being the most common, and the acquired anomalies with urethral stricture being the most common of them. Hypospadias is found commonly in newborn boys and it seen in approximately 8.2 per 1000 births. The goal of hypospadias reconstruction are to bring the meatus close to glans to allow the child to void standing, removing the chordee to allow for normal sexual intercourse and giving the phallus appearance of a normally circumcised penis when observed from distance. There are more than 200 named surgical procedure to correct hypospadias. Now a days tubularized incised plate (TIP) urethroplasty described by Snodgrass in 1994 is the most common procedure used for repair of hypospadias. The advantages of this technique include its simplicity, high success rate, low rate of complication and excellent cosmetic results. A lot of modifications were introduced on the TIP urethroplasty aiming to improve the success rate and to decrease fistula formation. We were from the firsts who published such modification regarding the use of double- layer dartos flap covering for urethra instead of the classic way of utilizing dorsal dartos flap (button hole maneuver). The second cause of urethroplasty is the acquired anomalies. Strictures of urethra is of much clinical important than hypospadias, because it bothers the patients more, unfortunately the results of surgery is not promising as that of hypospadias. The term “urethral stricture” refer to anterior urethral disease or scaring process involving the spongy erectile tissue of the corpus spongiosum (spongiofibrosis). According to World Health Organization posterior urethral stricture are not included in the common definition of urethral stricture www.intechopen.com 34 Current Concepts of Urethroplasty and the term stricture is limited to the anterior urethra. Urethral disruption injuries typically occur in conjunction with multisystem trauma from vehicular accident, falls, or industrial accident. Because the posterior urethra is fixed at both the urogenital diaphragm and the puboprostatic ligaments, the bulbomembranous junction is more vulnerable to injury during pelvic fractures. When the fracture occur the two separated ends fill with scar tissue, resulting in a complete lack of urethral continuity. The location of urethral strictures was classified as penile(including navicularis fossa) , bulbar or posterior (excluding bladder neck contractures).While posterior urethral strictures were commonly caused by traumatic disruption distinctly different from etiology compared to that of anterior strictures disease, recurrence was monitored with the same procedure used for surveillance of anterior urethral reconstruction. The Urethral disruption is heralded by the triad of blood at the meatus, inability to urinate, and palpably full bladder. When blood at the urethral meatus is discovered, an immediate retrograde urethrogram should be performed to rule out urethral injury.When urethral stricture is diagnosed immediate suprapubic tube placement remains the standard of care. While the diagnosis of hypospadias needs no radiologic tests, diagnosis of urethral stricture is a matter of discussion. The most common primary diagnostic tests are uroflowmetry (56%), urethrography (51%) and cystourethroscopy (21%). Definition of recurrence of stricture or failure of surgery is also a questionable issue. In 75% of papers regarding urethroplasty, recurrence was defined as the need for additional surgical procedure and in 52% as the need for additional urethral dilation. The treatment of urethral strictures is divided in two groups; endoscopic and open surgery. The endoscopic treatment such as direct-vision internal urethrotomy are the best reserved for selected short urethral stricture. However when the defects are 1 cm or longer or when a significant corpus spongiofibrosis is present , endoscopic procedure such as cutting through the pelvic scare”cut-to-light” are ineffective. Despite the popularity of this procedure the failure rate after initial urethrotomy is reported to be at least 50%. The failure rate after the second urethrotomy is considered much higher and can be as high as 100%. Therefore there has been continuing discussion about the most appropriate use of urethrotomy, dilation, stenting, and intermittent self dilation. Question have also surfaced about the best technique for urethrotomy. There is no compelling evidence in the literature that any particular form of urethrotomy is more effective than another, whether using a cold knife or laser. The second treatment option is open surgical reconstruction. There are two kinds of open surgical techniques used for urethroplasty; anastomotic urethroplasty and substitution urethroplasty. Anastomotic urethroplasty involves excision of the strictures and primary anastomosis of urethral ends. Open posterior urethroplasty through a perineal anastomotic approach is the treatment of choice for the most urethral distraction injuries because it definitely cure the patient without the need for multiple procedure. Care must be taken to carefully and meticulously excise all fibrotic tissue from the proximal urethra margin until at least a 28 french bougie passes without resistance. Free tension end to end anastomosis is the procedure of choice when the scar is 1.5-2 cm long and this is highly successful procedure in more than 95% of cases. Urethroplasty remains the gold standard for the management of urethral stricture offering the lowest rate of stricture recurrence and in some circumstance the most cost-effective compared to repeat dilation or endoscopic incision. The limiting factors with anastomotic urethroplasty is the strictures length, in particular the length of component distal to bulbopenile junction. Anastomatic procedure in the bulbar www.intechopen.com Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques 35 urethra resulted in a significant impairment of erectile function initially which improved in the majority of cases with a low of long term erectile dysfunction. The second kind of urethroplasty is substitution urethroplasty. Recent advances in tissue graft sources and the introduction of tissue sealants improve surgical outcomes and minimize patients morbidity by decreasing the number of surgical procedures and the potential disfigurement related to graft site morbidity. Substitution urethroplasty can be performed as a one-stage procedure via an augmented anastomotic procedure, patch substitution (onlay procedure) or a circumferential patch, or two-stage procedure which involves the formation of a roof strip followed be second stage tubularization. It has been shown that the efficacy of both grafts and flaps was identical , but there was a much higher morbidity with penile skin flaps which were also more complex with higher morbidity. The graft which has been used included scrotal skin, oral mucosa, extragenital skin, bladder mucosa, and colonic mucosa. The success rate at average follow-up of 53 months was reported to be 60% for augmented anastomotic repair and 80% for onlay procedure. In conclusion urethroplasty especially in patients with urethral stricture required the urologist to be aware of the techniques which offer the patient the best success. Therefore different considerations have to be taken into account like length , location, anatomy and etiology of stricture. In comparison to reconstruction of urethral stricture, urethroplasty done due to hypospadias seems to be less complicated with high success rate at long term follow-up.