Transurethral reconstruction of fossa navicularis strictures with dorsal inlay buccal mucosa graft urethroplasty
M. Ryan Farrell, MD, MPH1, Samuel Nowicki, BS2, Alex J. Vanni, MD1.
1Lahey Hospital and Medical Center, Burlington, MA, USA, 2Tufts University School of Medicine, Boston, MA, USA.
BACKGROUND: Fossa navicularis strictures are a challenging clinical entity. Successful reconstruction not only involves the creation of a widely patent urethra, but also requires attention to cosmesis. We describe a novel technique of single stage urethroplasty for fossa navicularis strictures using a transurethral dorsal inlay buccal mucosa graft and review the outcomes for this approach to reconstruction that avoids splitting the glans.
METHODS: We conducted a retrospective review of a prospectively maintained urethral stricture database to identify all fossa navicularis strictures that were reconstructed with a single stage, transurethral dorsal inlay buccal mucosa graft urethroplasty between 5/2015 and 6/2020 at our institution. The surgical technique involved creation of transurethral dorsal urethrotomies down to healthy corpus spongiosum to allow for excision of a triangular wedge of fibrotic urethra. The fossa navicularis was calibrated to ensure the lumen was at least 20 Fr. A buccal mucosa graft was then tailored to the triangular defect and secured in place with 5-0 monocryl suture. Patients were discharged the same day with a 14 Fr Foley catheter that remained in place for 1 week. Primary outcomes were anatomic success, defined as the ability to pass a 17 Fr flexible cystoscope, and functional success, defined as the lack of obstructive voiding symptoms and no need for further procedures. Secondary outcomes were postoperative complications and patient satisfaction.
RESULTS: Of the 43 patients that underwent reconstruction of fossa navicularis strictures during this time period, transurethral dorsal inlay buccal mucosa graft urethroplasty was performed in 16 men. Mean age was 63.1 years (43.9-75.6) and mean stricture length was 1.7 cm (1.4-2.0). Stricture etiology included internal trauma (62.5%), idiopathic (25.0%), and lichen sclerosus (12.5%). Prior endoscopic procedures were done in 75% of patients. Over a median follow-up of 19.3 months (IQR 7.6-24.1), anatomic success was 93.8% (15/16) and functional success was 100% (16/16). The single anatomic recurrence was at 4.2 months postoperatively. No additional procedures were required. Urinary tract infection occurred in 25% (4/16). There were no instances of de novo erectile dysfunction, chordee, wound infection, or hematoma. All patients would recommend urethroplasty to others and all patients were either very satisfied (83.3%) or satisfied (16.7%) with the procedure. Penile sensitivity was unchanged in 83.3%, increased in 8.3% and decreased in 8.3%.
CONCLUSIONS: Transurethral dorsal inlay buccal mucosa graft urethroplasty is a viable option for reconstruction of fossa navicularis strictures that avoids splitting the glans and results in excellent cosmesis.
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