The Robotic Buccal Mucosa Graft Ureteroplasty
Matthew J. Moynihan, MD, MPH, David Canes, MD, Alex J. Vanni, MD, Alireza Moinzadeh, MD, MHL.
Lahey Clinic, Burlington, MA.
Background: Radiation-induced urethral stricture disease (R-USD) creates surgical challenges for the reconstructive urologist due to the high risk of stricture recurrence and postoperative urinary incontinence (UI). We reviewed the outcomes of such patients at our institution to determine if conservative management can be an effective strategy.
Methods: We retrospectively identified patients with R-USD who were managed with observation, endoscopic management, and/or clean intermittent catheterization (CIC). Any patient who had an obliterative stricture, underwent urethral reconstruction, or had less than 3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, post void residual (PVR), and UI status. Secondary outcome measures were Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM), Sexual Health Inventory for Men (SHIM), and Male Sexual Health Questionnaire (MSHQ) scores.
Results: A total of 61 men met inclusion criteria between 2007-2019, with a median follow-up of 23.4 months (IQR 8.4 - 40.3). Median age was 77.9 years, body mass index was 27.1 kg/m2, and Charlson comorbidity index was 6. The indication for pelvic radiation was prostate cancer in 95% and colorectal cancer in 5%. The vast majority received external beam radiation (70%) or brachytherapy (28%). Of those with prostate cancer, 93% received radiation as primary therapy and 7% received adjuvant or salvage radiation. There were no salvage prostatectomies in this cohort. Median stricture length on urethrogram imaging was 2 cm (IQR 2-3). Stricture location was: bulbar (31%), bulbomembranous (49%), and prostatic (20%). The most common urinary symptoms were slow flow (57%), urgency/frequency (26%), and nocturia (21%). A total of 51 (83%) patients underwent subsequent urethral dilation and 20 (33%) underwent subsequent direct visual internal urethrotomy (DVIU). Median number of dilations and DVIUs per patient was 3 (IQR 1-7) and 1.5 (IQR 1-3), respectively. CIC was utilized in 39% of patients. Six (10%) patients had an AUR episode requiring urgent treatment and 27 (44%) had a stricture-related UTI. Median serum creatinine, PVR values, and questionnaire scores remained stable between first and last visits (Table 1). UI was reported in 49% of patients at first visit and 57% at most recent visit. Median number of pads per day minimally changed (1 vs. 2) and median number of diapers per day remained stable (1 vs. 1).
Conclusion: Although certain patients will desire urethral reconstruction, many patients with R-USD appear to be safely managed with conservative management with minimal effect on UI. Close observation is warranted due to the risk of stricture-related UTIs and AUR episodes. 
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