Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

Abstract

Study Need and Importance: Radiation and surgery remain the primary treatments for intermediate-and high-risk localized prostate cancer. Anastomotic stenosis is a known sequela of these treatments with varying incidence rates depending on surgical approach and type of radiation. Endoscopic attempts to manage these patients are universally ineffective, and excisional urethroplasty techniques for the repair of postradiation anastomotic stenosis have substantial rates of new stress urinary incontinence (SUI), ranging from 18% to 71%, likely due to tissue excision in proximity of the external sphincter. Treatment of anastomotic stenosis after both prostatectomy and radiotherapy is understudied. We analyzed a multi-institutional series of radiated postprostatectomy men who underwent dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) for posterior anastomotic stenosis and hypothesize that D-BMGU is technically feasible in this population with durable patency while minimizing new SUI. What We Found: In our cohort of 45 patients, 38 were patent at a median follow-up of 21 months (IQR 12-24), and there were no incidents of de novo SUI. Of the 7 recurrences only 2 occurred after 12 months. We found no evidence of differences in recurrence rate based on stricture location (P [ .65) or timing of prostatectomy (P [ .13). Postoperatively patients reported significant improvement in International Prostate Symptom Score, International Prostate Symptom Score qualityof-life domain, and postvoid dribble (P < .0001), and median postvoid residual and maximum urine flow rate significantly improved (P < .0001) Limitations: This technique cannot be used for obliterative stenosis or anastomotic disruption. The retrospective nature of this study along with variations between institutions in preoperative and postoperative protocols potentially introduces selection bias (Figure). Interpretation for Patient Care: D-BMGU is safe, feasible, and a durable reconstructive technique in patients with posterior urethral stenosis after both prostatectomy and radiotherapy. Zero patients experienced new SUI, and those with continued urinary incontinence were still able to undergo antiincontinence procedures if desired.

Complications of Prostate Cancer Treatment: Open Issues

“…The management of this complicated situation ranges from conservative and endoscopic treatment to different modalities of urethroplasty, either using excision and primary anastomosis or buccal mucosa graft urethroplasties. In this sense, a series with dorsal buccal graft augmentation urethroplasty has been recently published by the same group with very satisfactory results in this complex scenario [ 12 ].…”