Muscle- and Nerve-sparing Bulbar Urethroplasty: A New Technique Guido Barbagli, Stefano De Stefani, Filippo Annino, Cosimo De Carne, Giampaolo Bianchi  European Urology  Volume 54, Issue 2, Pages 335-343 (August 2008) DOI: 10.1016/j.eururo.2008.03.018 Copyright © 2008 European Association of Urology Terms and Conditions

Fig. 1 Ventral oral mucosal onlay graft urethroplasty: (A) The bulbospongiosum muscle is separated from the corpus spongiosum leaving the lateral margins of the muscle and the central tendon of perineum intact. (B) The bulbospongiosum muscle is pulled down, exposing the ventral urethral surface. (C) The corpus spongiosum is opened along the midline, and the ventral urethral surface is fully exposed. (D) The oral mucosal graft is sutured to the proximal and distal apices and to the left margin of the urethral mucosal plate. (E) The graft is rotated and sutured to the right margin of the mucosal urethral plate. (F) The corpus spongiosum is closed over the graft, and fibrin glue is injected over the corpus spongiosum. (G) The bulbospongiosum muscle is picked up to cover the corpus spongiosum. European Urology 2008 54, 335-343DOI: (10.1016/j.eururo.2008.03.018) Copyright © 2008 European Association of Urology Terms and Conditions

Fig. 2 Dorsal oral mucosal onlay graft urethroplasty: (A) The bulbar urethra is dissected from the corpora cavernosa, leaving the bulbospongiosum muscle and the central tendon of the perineum intact. (B) The urethra is rotated 180 degrees, and the dorsal urethral surface is fully opened. (C) The urethra is moved to the right side, and fibrin glue is injected over the corpora cavernosa. (D) The graft is fixed over the fibrin glue bed. (E) The distal and proximal apices of the graft are sutured to the apices of the urethrotomy. (F) The urethra, with the intact bulbospongiosum muscle, is rotated to cover the graft. (G) The graft is covered by the urethra, and fibrin glue is injected over the urethra. European Urology 2008 54, 335-343DOI: (10.1016/j.eururo.2008.03.018) Copyright © 2008 European Association of Urology Terms and Conditions

Fig. 3 Operating field after standard bulbar urethroplasty: The bulbospongiosum muscle is clearly damaged on both sides laterally. This damage is determined during the dissection of the muscles from the urethral bulb and by the retractor branches. It is evident that the main fibers of the nerves (laterally) as well as the fine branches going into the bulb of the urethra (medially) are both destroyed. Even if we could try to reconstruct the muscles, their function will never be restored. European Urology 2008 54, 335-343DOI: (10.1016/j.eururo.2008.03.018) Copyright © 2008 European Association of Urology Terms and Conditions

Fig. 4 Injury of the perineal nerves during a standard bulbar urethroplasty: The perineal nerves may likely be damaged at their emergence from the ischiorectal fossa or when the bulbospongiosum muscle is divided along the midline (red outline). European Urology 2008 54, 335-343DOI: (10.1016/j.eururo.2008.03.018) Copyright © 2008 European Association of Urology Terms and Conditions