Versatile algorithmic midline approach to perineal urethrostomy for complex urethral strictures

Purpose: To present results of an algorithmic approach to perineal urethrostomy (PU) based on a midline perineal incision among men with complex urethral strictures. Methods: A single surgeon retrospective review of consecutive patients who underwent PU between 2008 and 2017 was performed. Patient demographics and outcomes were collected via medical record review. After a midline perineal incision, the PU was matured either by (a) mobilization of the urethral plate (loop) alone in cases with distal strictures or low body mass index (BMI), or (b) with creation of a lateral perineal skin flap (7-flap) for those with longer urethra-to-skin distances. Success was defined as functional voiding without the need for further procedures. Patients were contacted by phone and administered validated questionnaires. Results: Of 62 PU patients, 20 (32.3%) underwent the loop technique, and 42 (67.7%) had the 7-flap procedure, 7 of which were reoperative for prior failed PU. Median age was 61.9 years (range 23–85) and the median stricture length was 8.0 cm (range 2.5–18 cm). Mean BMI was greater among 7-flap compared to loop patients (34.9 vs. 30.0 kg/m², p = 0.01). Success rates were 92.9% (39/42) in the 7-flap group and 100% (20/20) in the loop PU cohort during a median follow-up of 30.7 months. Among 62 PU patients, 19 (30.6%) responded to the survey—median PGI-I score was 1.0 (range 1–2) indicating that symptoms were “very much improved”. Conclusions: The algorithmic midline approach to PU offers a standardized, versatile solution with excellent surgical outcomes and high patient satisfaction, even in obese or refractory stricture patients.