Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures

Abstract

Background Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra. Objective To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction. Design, setting, and participants Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study. Surgical procedure The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula. Measurements Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure. Results and limitations We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5–8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5–26 ml/min). The median follow-up was 25 mo (IQR 10–30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique. Conclusions In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra. Patient summary Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.

Bilateral T-shaped Scrotoplasty as an Ancillary Technique of Staged Anterior Urethroplasty: The End Justifies the Means

“…The combined technique of Joshi et al using buccal graft dorsally plus fasciocutaneous penile flap ventrally could be a feasible option, augmenting the urethra up to a 28.6 French caliper, however, requiring an additional circumcising subcoronal incision. He reported in a series of 15 patients a primary success rate of 86.7%, defined as no need for any kind of instrumentation, while the secondary success rate was 73.3%, defined as a Qmax under 10 ml/s or new obstructive LUTS [15]. Although we occasionally use Joshi's technique, in this case, given the severe spongiofibrosis and compromised tissue vascularization, we preferred a staged technique to maximize the chances of graft take.…”

Optimizing decision‐making after ventral onlay buccal mucosa graft urethroplasty failure

“…Third, the effect of predictive factors on risk of failure of ventral BMG urethroplasty was estimated using the Kaplan-Meier method and compared using log-rank tests. Fourth, for those patients who failed ventral BMG urethroplasty and underwent a rescue treatment, namely, DVIU vs open urethroplasty with graft or flaps [21], the probability of success after retreatment was assessed. Furthermore, to assess the effect of repeat DVIU vs open surgery, we analysed the risk of failure at 12 months with Kaplan-Meier and regression tree analyses in patients receiving only rescue DVIU (91 patients), or second rescue DVIU (40 patients), or third rescue DVIU (16 patients).…”

Editorial Comment

“…Urethroplasty is a challenging surgical procedure with high risk of developing both intra-and postoperative complications, especially in those patients suffering from strictures with high-risk features. 1,2 Nevertheless, data on complications after urethroplasty are sparse in literature with a wide range of incidence reported (1%e38%). This heterogeneity might be explained by the variability in the definition and reporting of complications.…”

“…Previously, Kim et al identified the presence of positive preoperative cultures to be a risk factor for postoperative UTIs (OR 6.7, p[0.012). 2 The judicious use of antibiotics continues to be an area of emphasis, in an effort to minimize adverse effects and prevent antibiotic resistance. However, there is no standardized management paradigm used by reconstructive urologists.…”