Innovative Approaches for Complex Penile Urethral Strictures

Jordan Siegel; Timothy J. Tausch; Jay Simhan; Allen F. Morey

Disclosures

Transl Androl Urol. 2014;3(2):179-185. 

In This Article

Combined Dorsal and Ventral Buccal Mucosa Grafting

An alternative approach in cases of long strictures with inadequate urethral plate is a combined dorsal and ventral buccal graft. Palminteri and colleagues initially described their technique in a group of 48 patients with bulbar strictures.[43] Their technique combined the dorsal inlay approach of Asopa[44] with a ventral onlay graft as described by Elliott.[45] Of the initial 48 cases, 43/48 (89.6%) were successful at 22 months follow up ('success' defined by voiding normally without the need for any additional post-operative procedures). Onsubsequent follow up of 48.9 months, 64 of 73 patients (88%) were voiding normally. Erectile function was preserved in all patients undergoing repair.[46]

Goel and colleagues, who had previously reported utilizing combined grafts for meatoplasty,[47] recently compared a dorsal buccal graft placement to a combined dorsal and ventral graft placement in 20 patients with pendulous urethral strictures.[48] With ten patients in each group, group 1 underwent Asopa inlay only[44] while group 2 underwent an Asopa inlay with an additional ventrally placed graft. Both groups were well matched based on stricture length (7.2 vs. 7.5 cm), etiology, and location. Success rates were comparable (7/10 vs. 8/10) at follow up of 35.7 months and 31.8 months, for groups 1 and 2 respectively. It is noteworthy that longer surgical times were noted in the combined graft group but the complication rates remained similar.

We have previously published our institution's experience with combined dorsal and ventral buccal mucosa grafting for complex anterior urethral stricture with obliterative or near-obliterative segments.[49] Mean stricture length was 4.5 cm with a varied stricture location, 39% of patients having involvement of the pendulous urethra. Our technique involved a ventral approach to the strictured urethral segment as previously described.[44] In obliterative urethral segments (<5 mm width), the urethra was excised and a dorsal graft was quilted onto the corporal bodies to recreate the urethral plate (Figure 1A,B). Alternatively if the strictured segment was wider (5–10 mm), the urethral plate was divided longitudinally and a graft was quilted dorsally to enhance its width. We then completed our circumferential repair with a ventral onlay graft (Figure 1C),[24] with dartos/tunica vaginalis flap coverage in areas of insufficient spongiosum (Figure 1D). Postoperative VCUG demonstrated excellent patency of the repair (Figure 2). Of our 36 cases performed, 32 patients (89%) demonstrated successful outcomes, as defined by voiding normally without the need for additional procedures at a follow up of 15.7 months.

Figure 1.

(A) Retrograde urethrogram demonstrating a severe pendulous urethral stricture; (B) The urethral plate is excised in the area of severe stricture; (C) A 1 cm buccal graft is placed dorsally to recreate the urethral plate in the area of excision, with a ventral buccal mucosa graft onlayed ventrally over the area; (D) A tunica vaginalis flap is utilized for coverage of the repair due to lack of sufficient spongiosal tissue.

Figure 2.

Postoperative VCUG from patient in Figure 1. The urethra is patent, demonstrating excellent result of the combined dorsal inlay and ventral onlay of the buccal mucosal graft repair.

Overall these studies have demonstrated success in a heterogeneous population of anterior urethral strictures with respect to etiology, location and stricture length. Since penile skin is not being utilized, this technique is suitable for lichen sclerosis or hypospadias where healthy penile skin may be deficient or diseased. As previously discussed, the microvascular structure of the buccal graft leads to excellent graft take, especially when applied dorsally with the blood supply provided from the tunica. In contrast, the ventrally placed graft must rely on the spongiosum for its blood supply. In cases of deficient spongiosum, such as with hypospadias or distal strictures where the corpus spongiosum tends to be less robust, we cover the graft with a tunica vaginalis or dartos flap.

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