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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 31  |  Issue : 2  |  Page : 46-50

Outcomes of urethroplasty for anterior urethral strictures: A single-center experience


Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

Date of Submission12-Aug-2019
Date of Decision07-Oct-2019
Date of Acceptance19-Oct-2019
Date of Web Publication25-Apr-2020

Correspondence Address:
Ta-Min Wang
Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan. No. 5, Fuxing Street, Guishan District, Taoyuan 33305
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_54_19

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  Abstract 


Purpose: The management of anterior urethral strictures is quite challenging due to high failure rates with many unavoidable postoperative complications. This study aims to elucidate the appropriate surgical techniques, advantages, and disadvantages of the different urethroplasties. Materials and Methods: We retrospectively recorded and analyzed twenty patients' demographics, surgical techniques, postoperative uroflowmetry, and complications. Patients were divided into two groups depending on the length of their strictures. Patients in Group 1 presented a urethral stricture or obliteration length of <3 cm and received excision and primary end-to-end anastomosed urethroplasty. Group 2 consisted of patients with a stricture or obliteration length of more than 3 cm who received buccal mucosa graft (BMG)-augmented dorsal onlay urethroplasty. The success rate and objective parameters following anastomosed or augmented urethroplasties were assessed over an 8-year follow-up period. Results: Despite the longer strictures and different number of complete obliterations, BMG-augmented urethroplasty exhibited comparable success rates (90%) with anastomosed urethroplasty (90%). The mean postoperative peak flow rates in the two groups were more than 15 mL/s, with Group 1 at 27.1 mL/s and Group 2 at 16.9 mL/s. No patients exhibited postoperative complications of incontinence or erectile dysfunction, no perineal wound infections were observed in any patient, and no significant complications were noted in the oral cavity where the buccal mucosa was harvested. Conclusion: Two conclusions were drawn from this clinical surgery experience. The first is that the type of urethral reconstruction should be considered according to the length of the urethral stricture. We suggest that urethral strictures longer than 3 cm are suitable for augmented urethral reconstruction. The second is that anatomical consideration of the urethra is also an important factor in choosing an appropriate urethroplasty. We recommend augmented urethral reconstruction for penile urethral strictures and anastomosed urethral reconstruction for bulbar urethral strictures.

Keywords: Urethroplasty, urethral reconstruction, urethral stricture


How to cite this article:
Chu YC, Wang TM, Wang HH, Chu SH, Chen HW, Chiang YJ, Liu KL, Lin KJ, Lin CT. Outcomes of urethroplasty for anterior urethral strictures: A single-center experience. Urol Sci 2020;31:46-50

How to cite this URL:
Chu YC, Wang TM, Wang HH, Chu SH, Chen HW, Chiang YJ, Liu KL, Lin KJ, Lin CT. Outcomes of urethroplasty for anterior urethral strictures: A single-center experience. Urol Sci [serial online] 2020 [cited 2020 May 24];31:46-50. Available from: http://www.e-urol-sci.com/text.asp?2020/31/2/46/283248




  Introduction Top


Urethral stricture is a common result of fibrotic attenuated change in the urethra after urethral trauma. Fibrosis typically extends into the periurethral tissue and contributes to spongiofibrosis, urethral lumen stenosis, and the loss of urethral expansibility. Sometimes, severe urethral stricture causes complete obliteration of the urethral lumen. Iatrogenic urethral strictures are also common and may be caused by repeated endourological procedures. In 1974, Sachse introduced treatment by direct vision internal urethrotomy (DVIU),[1] and the other popular management technique is urethral dilation. Several studies have thoroughly characterized the similar success of DVIU and urethral dilation.[2] In clinical practice, the management of urethral stricture is quite challenging due to high failure rates and many postoperative complications.[3],[4] If first-line management by urethral dilatation or DVIU fails, excision of the stricture and primary end-to-end anastomosis is suggested for short-segment strictures. Later, Humby first described the use of buccal mucosa graft (BMG) for urethral reconstruction.[5] Accordingly, BMG augmented or substitution urethroplasty is recommended for long urethral strictures. Although serious precautions are taken in performing this technique, the recurrence rate is still a problem in all types of urethroplasties. For a better prognosis, clinicians should know the appropriate techniques and indications of different types of urethroplasties. In this study, we assessed the success rate and objective parameters after anastomosed or augmented urethroplasties over an 8-year follow-up period.


  Methods Top


This retrospective study was performed on twenty patients who were admitted to the Department of Urology of Chang Gung Memorial Hospital in Taoyuan, Taiwan, from October 2010 to October 2018. Ethical approval for this study (IRB Number 201801174B0) was provided by the Ethical Committee NAC of Chang Gung Medical Foundation, Linkou, on 6 August 2018. Informed consent was received from all the patients. We recorded and compared patients' demographics, diagnostic investigations for anterior urethral strictures, surgical techniques, postoperative uroflowmetry, and complications. The exact length of the stricture after trauma and the injury site were diagnosed by retrograde urethrography (RU) and voiding cystourethrography (VCUG) simultaneously. A urethral Foley catheter was used to assess the distal end of the urethral stricture and obstruction. Most patients (16 of 20) did not respond to first-line management by DVIU or urethral dilatation.

Initially, our decision to choose which type of surgery, anastomosed or augmented urethroplasty, is based on the American Urological Association (AUA) guidelines on male urethral stricture and recent literature. Essentially, it is mainly based on the location of the urethral stricture to decide which kind of surgery to take, and then, we consider the length of the stricture. In fact, if it is a penile urethral stricture, regardless of the stricture length, the only choice is augmented urethroplasty. If it is a bulbar urethral stricture, we will then consider the length of the stricture. If the stricture length does not exceed 3 cm, it is mainly based on anastomosed urethroplasty. Other factors such as partial or complete obliteration, times of previous repair, and thickness of fibrotic tissue are not the focus of our consideration.

Patients were divided into two groups depending on the length of their stricture or obliteration. Patients in Group 1 presented a urethral stricture or obliteration length of <3 cm and received excision and primary end-to-end anastomosed urethroplasty. Group 2 consisted of patients with a stricture or obliteration length of more than 3 cm who received BMG-augmented dorsal onlay urethroplasty. Postoperative uroflowmetry was conducted to evaluate the status of the patients' self-urination. Postsurgical success was defined by a patient's ability to urinate by himself without a catheter. Other indicators of success included a normal postoperative uroflowmetry and/or urethral patency evaluated through the RU or VCUG. The success rate and objective parameters of these two urethroplasties were compared and analyzed.

Excision and end-to-end anastomosed urethroplasty

The patient was placed in the lithotomy position under general anesthesia. A longitudinal midline perineal incision was made 1 cm above the anal verge. The bulbospongiosus muscle was divided on the midline to expose the underlying urethra, and circumferential mobilization of the urethra was accomplished by dissecting the plane between the corpus spongiosum and the corpus cavernosum. The healthy distal urethral end was identified and divided from the stricture segment. The healthy proximal urethral end was also identified after excision of the stricture segment. The two urethral ends were then spatulated and anastomosed by interrupted polyglactin 4-0 sutures after stenting with an Fr16 silicone Foley catheter. The mobilized urethra was then anchored to the peripheral urethral bed to reduce the tension over the anastomosis site. The silicone catheter was removed on postoperative day 21. Then, the VCUG or RU was performed, and the results were compared with preoperative films. The uroflowmetry was monitored and recorded in the follow-up period.

Buccal mucosa graft-augmented urethroplasty

The midline perineal incision for bulbar urethral stricture to approach the urethral stricture segment was similar to that of the anastomosed urethroplasty. In the cases of penile stricture, a subcoronal circumferential incision was made and the penile skin was degloved. After identification of the stricture site, there was no attempt to mobilize the urethra or dissect the bulbospongiosus muscle. The urethra was split open ventrally over a urethral dilator, and the stricture segment was opened [Figure 1]. The incision was extended into the healthy urethra both proximally and distally. The full thickness of the urethra stricture's dorsal side was incised from the midline to the healthy tunica albuginea. This provided a raw, vascularized bed for receiving the BMG. Adequate sizes of BMGs were harvested and placed over the raw vascularized bed to cover the defect. The graft's margins were sutured to the edges of the incised urethra and to the underlying tunica albuginea with 5-0 interrupted polyglactin sutures [Figure 2]. The urethra was closed by continuous sutures over an Fr16 silicone Foley catheter. The silicone catheter was removed on postoperative day 28. Then, the VCUG or RU was performed, and the results were compared with preoperative films. The uroflowmetry was monitored and recorded in the follow-up period. The surgery was considered successful if the patient could urinate smoothly by himself without a catheter. Other successful indicators were a normal postoperative uroflowmetry and/or normal and unobstructed urethra evaluated through the RU or VCUG. If these indicators were not present, the surgery was considered a failure. The success rate and postoperative complications of anastomosed and augmented urethroplasties were compared.
Figure 1: Urethral stenotic segment was noted over the middle of the penile urethra

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Figure 2: Dorsal inlay augmentation with buccal mucosa after the first stitch

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  Results Top


A total of twenty patients underwent urethroplasty during the study period, with an average of 42.8 months of follow-up. The mean age of the urethroplasty group was 36.1 years. The mean age of the anastomotic urethroplasty group was 42.6 years [Table 1].
Table 1: Demographic factors of two groups

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We found that the main cause of urethral stricture was trauma, due to either traffic accidents or injuries from falling. Initially, most of our patients (80%) had undergone 1–4 DVIU endourological procedures. Group 1 included eight patients with complete urethral obliteration and two patients with partial urethral obliteration (average stricture length = 2.6 cm). All the ten patients underwent excision of the stricture and end-to-end anastomosis. One patient received redo-urethroplasty due to surgical failure, and the remaining nine patients were asymptomatic during an average follow-up of 50.9 months [Table 2]. The reason for the failure of the patient may be that the fibrotic tissue has not been completely removed and the stricture recurred. Later, the patient underwent a second urethral reconstruction and finally urinated quite smoothly. Group 2 patients, with an average stricture length of 3.7 cm, underwent BMG-augmented dorsal onlay urethroplasty. One patient had a recurrence of urethral stricture, whereas the other nine patients were asymptomatic during an average follow-up of 38.3 months. The patient of Group 2 was suffering from poor postoperative urinary flow because of the use of an insufficient length of BMG. Postoperative intermittent urethral dilatation was performed, and the symptoms gradually improved.
Table 2: Postoperative characteristics of anastomosed versus augmented urethroplasty groups

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According to the medical literature, the postoperative average peak flow rate for patients undergoing successful urethral reconstruction is about 15 mL/s. The mean peak flow rate in our two groups was more than 15 mL/s, with the first group at 27.1 mL/s and the second group at 16.9 mL/s [Table 2]. Despite the longer strictures and different number of complete obliterations, BMG-augmented urethroplasty exhibited comparable success rates (90%) with anastomosed urethroplasty (90%). No patients exhibited postoperative complications of incontinence or erectile dysfunction. One patient from Group 2 complained of an unsatisfying urinary stream. No perineal wound infections were observed in any patient. There were no significant complications at the oral cavity where the BMG was harvested.


  Discussion Top


In clinical practice, urethral stricture is typically managed by DVIU or urethral dilation.[1],[2] However, reported recurrence rates are as high as 68%–92%.[3],[4] The long-term outcome of endoscopic treatment is poor, thus contributing to the development of urethroplasty techniques.[5],[6] Although urethroplasty has been shown to yield superior outcomes, many urologists are reluctant to offer urethroplasty and prefer repeat urethrotomies instead. This reluctancy is a result of unfamiliarity with urethroplasty techniques, as most urologists have little experience with urethroplasty during urological residence training. Our department has attempted to overcome the problem of relatively low case numbers by establishing a single surgical team for the management of urethral strictures. We concluded that the factors for successful outcome depend on having a surgical team dedicated only to conducting urethroplasties. Furthermore, this study focused on two types of urethroplasties: anastomosed and augmented.

Although urethral strictures shorter than 2 cm are usually recommended for anastomosed urethroplasty, we are flexible regarding this criterion. Sometimes, a case with a stricture longer than 2 cm can also be arranged for anastomosed urethroplasty.[6],[7] Therefore, we suggest that the final decision of which urethroplasty should be performed is made in the operation room. Obviously, the length of the urethral stricture is an important element in deciding which type of urethroplasty is necessary. Eltahawy and several other researchers observed a high success rate for excision and primary anastomosis for bulbar strictures measuring 0.5–4.5 cm.[6],[7] However, it is well known that longer urethral strictures should not be addressed by anastomosed urethroplasty, and another procedure, such as augmented urethroplasty, can be used. Even so, augmented urethroplasty has shortcomings and limitations. Clinically, most long-segment strictures that are repaired using flaps or grafts have lower long-term success, potentially due to shrinkage of ischemic tissue or the requirement of multiple operations.[8] Therefore, it is very important to carefully select the appropriate urethroplasty for each patient with adequate length of urethral stricture.

According to literature reviews, the most accepted suggestion for treating a long urethral stricture is augmented urethroplasty.[9],[10] Augmentation can be performed with different body tissues, such as prepuce, scrotal skin, urinary bladder mucosa, and buccal mucosa.[11] Among these, buccal mucosa has been an ideal urethral substitute, and BMG is easily harvested under general anesthesia. It is hairless and compatible in a wet environment and is easily taken up by the urethral bed. All these unique characteristics make buccal mucosa an integral part of reconstructive urology. However, there is controversy as to whether BMG should be placed dorsally or ventrally. In the penile urethra, most urologists would place it dorsally. Nevertheless, most urologists place it ventrally, dorsally, and even laterally in the bulbar urethra.[12],[13],[14],[15],[16] Multiple studies have shown that both dorsal and ventral onlay BMGs result in good blood supply and mechanical support.[16],[17] Barbagli et al. showed that success rates are equal between dorsal and ventral BMG urethroplasties.[12] The success rate of dorsal onlay and ventral onlay BMG graft placement is equivalent (84%–100%). The Asopa technique, which is similar to the dorsal onlay procedure, was used for augmented urethroplasty in the penile urethral strictures of our patients. In our study, two commonly used techniques, end-to-end anastomosed and BMG dorsal onlay-augmented urethroplasties, were compared. The success rate of augmented urethroplasty is 90%, which is equal to that of anastomosed urethroplasty in this study.

Anatomical consideration of the urethra is another important factor in choosing which type of urethroplasty should be used. In fact, the anterior urethra is divided into bulbar and penile urethras. The bulbar urethra, which is more moveable than the penile urethra, can be mobilized to allow for the excision of a stricture and a tension-free primary anastomosis. However, this technique is not possible in the penile urethra, which is more fixed by the surrounding tissue. Anastomosed urethroplasty for penile urethra might bring the risk of decreased length and cause curvature during erection. This means that reconstructive urethroplasty in the penile urethra is limited to augmentation using free grafts or flaps. Therefore, we always prevent anastomosed urethroplasty for penile urethral stricture in our clinical practice because the risk of penile curvature is a common concern for patients. Moreover, penile urethral strictures tend to be longer than bulbar urethral strictures.[18] Certainly, the disadvantages of grafts on the penile shaft are the potential graft contracture and penile curvature. For these reasons, penile urethral reconstruction is technically more challenging than bulbar urethral reconstruction. Although there are many challenges, augmented urethroplasty is still the first choice for nonobliterated penile urethral strictures.[19] According to our experience, positive results are possible if the type of surgery is chosen depending on the length and position of the urethral stricture. However, in addition to being a retrospective study, a shortcoming of this article is that it is limited to one medical center and the sample population is relatively small.


  Conclusion Top


Two conclusions were drawn from this clinical surgery experience. The first is that the type of urethral reconstruction should be considered according to the length of the urethral stricture. We suggest that urethral strictures longer than 3 cm are suitable for augmented urethral reconstruction. The second is that anatomical consideration of the urethra is also an important factor in choosing an appropriate urethroplasty. We recommend augmented urethral reconstruction for penile urethral strictures and anastomosed urethral reconstruction for bulbar urethral strictures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Smith P, Dunn M, Dounis A. Sachse optical urethrotome in management of urethral stricture in the male: Preliminary communication. J R Soc Med 1978;71:596-9.  Back to cited text no. 1
    
2.
Steenkamp JW, Heyns CF, de Kock ML. Internal urethrotomy versus dilation as treatment for male urethral strictures: A prospective, randomized comparison. J Urol 1997;157:98-101.  Back to cited text no. 2
    
3.
Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: Long-term followup. J Urol 1996;156:73-5.  Back to cited text no. 3
    
4.
Santucci R, Eisenberg L. Urethrotomy has a much lower success rate than previously reported. J Urol 2010;183:1859-62.  Back to cited text no. 4
    
5.
Humby G. A one-stage operation for hypospadias repair. Br J Surg 1941;29:84-92.  Back to cited text no. 5
    
6.
Eltahawy EA, Virasoro R, Schlossberg SM, McCammon KA, Jordan GH. Long-term followup for excision and primary anastomosis for anterior urethral strictures. J Urol 2007;177:1803-6.  Back to cited text no. 6
    
7.
Park S, McAninch JW. Straddle injuries to the bulbar urethra: Management and outcomes in 78 patients. J Urol 2004;171:722-5.  Back to cited text no. 7
    
8.
McAninch JW, Morey AF. Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures. J Urol 1998;159:1209-13.  Back to cited text no. 8
    
9.
Bhargava S, Chapple CR. Buccal mucosal urethroplasty: Is it the new gold standard? BJU Int 2004;93:1191-3.  Back to cited text no. 9
    
10.
Morey AF, McAninch JW. When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology 1996;48:194-8.  Back to cited text no. 10
    
11.
Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol 1998;160:1307-9.  Back to cited text no. 11
    
12.
Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M, et al. Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: Are results affected by the surgical technique? J Urol 2005;174:955-7.  Back to cited text no. 12
    
13.
Barbagli G, Selli C, di Cello V, Mottola A. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. Br J Urol 1996;78:929-32.  Back to cited text no. 13
    
14.
Elliott SP, Metro MJ, McAninch JW. Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754-7.  Back to cited text no. 14
    
15.
Dubey D, Kumar A, Bansal P, Srivastava A, Kapoor R, Mandhani A, et al. Substitution urethroplasty for anterior urethral strictures: A critical appraisal of various techniques. BJU Int 2003;91:215-8.  Back to cited text no. 15
    
16.
Iselin CE, Webster GD. Dorsal onlay urethroplasty for urethral stricture repair. World J Urol 1998;16:181-5.  Back to cited text no. 16
    
17.
Kellner DS, Fracchia JA, Armenakas NA. Ventral onlay buccal mucosal grafts for anterior urethral strictures: Long-term followup. J Urol 2004;171:726-9.  Back to cited text no. 17
    
18.
Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral strictures: Etiology and characteristics. Urology 2005;65:1055-8.  Back to cited text no. 18
    
19.
Campos-Juanatey F, Bugeja S, Ivaz SL, Frost A, Andrich DE, Mundy AR. Management of penile urethral strictures: Challenges and future directions. World J Clin Urol 2016;24:1-10.  Back to cited text no. 19
    


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