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Urethroplasty for high-risk, long segment urethral strictures with ventral buccal mucosa graft and gracilis muscle flap
Drew A. Palmer, MD1, Jill C. Buckley, MD2, Leonard N. Zinman, MD1, Alex J. Vanni, MD1.
1Lahey Hospital and Medical Center, Burlington, MA, USA, 2University of California, San Diego, CA, USA.
BACKGROUND:
End-stage urethral stricture disease presents a reconstructive challenge that frequently results in urinary diversion. Our objective was to assess the success of urethral reconstruction for high-risk, long segment urethral strictures with a ventral buccal mucosa graft (BMG) and gracilis muscle flap (GMF) in patients who were unfit for standard repair because of a poor graft bed.
METHODS:
A retrospective review of 1039 patients who underwent urethroplasty at a tertiary care hospital between 1999 and 2013 was performed. We identified 18 patients who underwent urethroplasty with ventral BMG and GMF buttress as a graft bed. Patient demographics, stricture etiology, length, location, prior surgical procedures and surgical approach were identified. Stricture recurrence was defined as the inability to pass a 16 Fr cystoscope.
RESULTS:
The mean age was 60.2 years (23-81) at the time of surgery with a mean follow-up of 39.3 months (6-92). The mean stricture length was 8.2 cm (3.5-15). Stricture etiology included radiation therapy (50%), failed urethroplasty (16.7%), trauma (11.1%), prostatectomy (11.1%), hypospadias failure (5.6%), and endoscopic instrumentation (5.6%). 7 patients (38.9%) had previous urethroplasty and 3 (16.7%) had previous UroLume® Urethral Stents placed. The strictures were located in the posterior urethra with or without involvement of the bulbar urethra in 55.6%, followed by the bulbomembranous urethra (33.3%), bulbar urethra (5.6%), and penile urethra (5.6%). Urethral reconstruction was successful in 14 out of 18 patients (77.8%). Of the four failures, one had an ileal loop, two were managed with a suprapubic tube, and the fourth was managed with urethral dilation. Mean time to stricture recurrence was 9 months (2-17). 5 patients (27.8%) had postoperative incontinence requiring an artificial urinary sphincter.
CONCLUSIONS:
Urethroplasty for high-risk, long segment urethral strictures can be successfully performed with a ventral BMG and GMF avoiding urinary diversion in the majority of patients.
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