Single‐stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosal grafts

Abstract

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? This technique has been reported to have an excellent success rate in the bulbar urethra, although no data exists for its use in the penile urethra. This is the first study to report successful use of the technique in the reconstruction of penile urethral strictures. OBJECTIVE To review our initial experience with single‐stage overlapping dorsal and ventral buccal mucosa graft (BMG) urethroplasty for the reconstruction of complex anterior urethral strictures. PATIENTS AND METHODS Among 696 urethroplasties performed at two tertiary urethroplasty centres from October 2007 to September 2010, single‐stage urethral reconstruction using urethral plate incision and/or excision and overlapping dorsal and ventral BMGs was used in 36 men (5%) with complex urethral strictures (mean length 4.5 cm). Demographic and perioperative data was tabulated and outcomes were analysed. RESULTS Stricture location was bulbar (61%), penile (19%), or both bulbar and penile (20%). Dorsal grafts, applied only within the most severely strictured segment, measured a mean 42% of the opposing ventral graft length. At a mean follow‐up of 15.7 months, 32 of the 36 cases were successful (89%). Repeat urethroplasty was performed in all four recurrences, three of which were successful at a mean follow‐up of 16 months. CONCLUSION Single‐stage reconstruction of focally obliterative long urethral strictures using overlapping dorsal and ventral BMGs is safe and effective.

Urethroplasty for Stricture Disease: Contemporary Techniques and Outcomes

“…39 In an expanded assessment of OBMGU, a recent multi-institutional analysis of 36 patients validated these promising results for strictures along the entire anterior urethra with an 89% success rate following a mean of 16 months after urethroplasty. 10 Gelman et al described a similar version of OBMGU through a dorsal approach, thus preserving the ventral corpus spongiosum. 17 This technique utilizes circumferential urethral mobilization and a dorsally-placed buccal mucosal graft, as Barbagli described.…”

“…17 This involves resection of the obliterated segment, recreating the dorsal urethral surface by grafting, and with the ventral surface replaced by a penile skin flap 18 or another graft supported by dartos or tunica vaginalis. 10 Staged urethroplasty gained greater use in the 1990s after Bracka reported this in the setting of prior failed hypospadias repair. 19 Here, the entire circumference of the urethra is excised and a new urethral plate created by a wide graft placed on the ventral surface of the penis.…”

“…The OBMGU concept allows use of more narrow ventral grafts, and thus less likelihood of sacculation. 10,39 Importantly, this technique avoids tubularized grafts and urethral transection. Palminteri et al reported an 88% success rate in 73 patients with bulbar strictures undergoing OBMGU.…”

“…A minimum lumen size of 5Fr or a urethral plate of 5 mm or greater is recommended for straightforward onlay procedures. 10 Pedicled penile skin flaps consist of a skin island mobilized on its tunica dartos pedicle. Ventral flap onlay is generally preferred due to its simplicity, as dorsal tissue transfer requires mobilization of the densely-adherent penile urethra from the corporal bodies.…”

“…Another recent technique supports a ventral graft in the distal bulb with "pseudospongioplasty," covering the graft with by tunica dartos or tunica vaginalis where the ventral spongiosum is inadequate 10. Augmented Anastomotic Urethroplasty (AAU) AAU combines urethral scar resection with an onlay graft.…”