- Graft take requires ≈96 hours in 2 phases: imbibition (≈48 hours, graft "drinks" nutrients from host bed) and inosculation (≈48 hours, true microcirculation reestablished).
- Split-thickness grafts have favorable vascular characteristics but tend to contract and be brittle when mature; full-thickness grafts are more durable but have more fastidious vascular characteristics.
- Buccal mucosa is thought to have a panlaminar plexus, making it a preferred graft for primary urethral reconstruction.
- "Urethral stricture" refers to anterior urethral disease involving the epithelium and corpus spongiosum (spongiofibrosis); posterior urethral narrowing is termed contracture, stenosis, or PFUI.
- Most common cause of urethral stricture: trauma (most common cause in developing countries — usually straddle injury); idiopathic is most common in developed countries.
- DVIU: single incision usually at 12 o'clock; most common complication is stricture recurrence; multiple prior dilations/urethrotomies diminish success of subsequent reconstruction.
- Open reconstruction principles: total excision of fibrosis, widely spatulated ovoid anastomosis, tension-free anastomosis; lithotomy position.
- Excision with primary anastomosis should be avoided in patients with prior hypospadias repair due to altered retrograde glans blood supply.
- PFUIs accompany ≈10% of pelvic fractures; distraction injuries are unique to the membranous urethra, most frequently at the bulbomembranous junction.
- Cystogram in PFUI provides info on rostral displacement of proximal urethra, bladder outline, and bladder neck competency.
- Maneuvers for distracted proximal urethra in PFUI repair: corpus spongiosum mobilization, intracrural space development with bulbospongiosus detachment, sequesterectomy, corporeal rerouting, infrapubectomy.
- Boots in exaggerated lithotomy must avoid stretch injury to the common peroneal (fibular) nerve — damage causes foot drop; sensation: posterolateral leg and knee joint.
- Femoral nerve (L2-L4): largest branch of lumbar plexus; sensory to anterior thigh/medial leg; motor to knee extension; can be injured by hip hyperabduction/hyperextension or retractor injury.
- Lichen sclerosis (formerly balanitis xerotica obliterans): most common cause of meatal stenosis in adults; primarily middle-aged uncircumcised men; capable of malignant transformation to SCC in 2-8%.
- LS treatment: topical clobetasol or mometasone; oral mucosal grafting preferred for LS-associated strictures (genital skin is inappropriate); circumcision may be curative if only foreskin involved.
- Permanent ejaculatory dysfunction may occur in up to 20% after urethroplasty; temporary ED also up to 20%, with <3-4% permanent — rate similar to circumcision.
- Forearm flaps are most commonly used for total phallic construction; prosthetic implantation deferred 1 year until protective sensibility demonstrated.