New Frontiers in Urethral Reconstruction

Injectables and Alternative Grafts

Alex J. Vanni

Disclosures

Transl Androl Urol. 2015;4(1):84-91. 

In This Article

Abstract and Introduction

Abstract

Contemporary management of anterior urethral strictures requires both endoscopic as well as complex substitution urethroplasty, depending on the nature of the urethral stricture. Recent clinical and experimental studies have explored the possibility of augmenting traditional endoscopic urethral stricture management with anti-fibrotic injectable medications. Additionally, although buccal mucosa remains the gold standard graft for substitution urethroplasty, alternative grafts are necessary for reconstructing particularly complex urethral strictures in which there is insufficient buccal mucosa or in cases where it may be contraindicated. This review summarizes the data of the most promising injectable adjuncts to endoscopic stricture management and explores the alternative grafts available for reconstructing the most challenging urethral strictures. Further research is needed to define which injectable medications and alternative grafts may be best suited for urethral reconstruction in the future.

Introduction

The management of urethral strictures is varied and includes both endoscopic and open urethral reconstruction, with the goal of improving urinary flow. Urethral strictures resulting from trauma, iatrogenic injury, prior hypospadias surgery, lichen sclerosis and previous urethral reconstruction often result in long segments of urethra that require extensive reconstruction. The optimal management of a urethral stricture is dependent on a multitude of factors including the location, length, and etiology of stricture, as well as the surgeon's experience and reconstructive preference. Urethral strictures are often managed in a progressive manner in which shorter strictures are managed endoscopically or with excision and anastomosis, while augmentation with oral mucosa grafts or fasciocutaneous flaps are necessary for longer defects.

While the buccal mucosa graft is the workhorse of urethral reconstruction, a need exists for alternative grafts for augmentation urethroplasty in patients in whom obtaining adequate graft material is difficult; namely long segment, panurethral strictures or recurrent strictures in patients who have had prior buccal mucosa graft retrieval. Buccal mucosa is now used so frequently, and with such high success, that many of the grafts we used in the past (genital and extragenital skin), are a great source to re-examine in the future. Additionally, tissue engineering and regenerative medicine offers the potential to significantly reduce the invasiveness and morbidity of urethral reconstruction by having off the shelf material available, with the goal of improving patient outcomes.

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