Urethral strictures in children

Paediatric Buccal Mucosal Graft Urethroplasty for Non-Hypospadias Urethral Strictures: A Single Centre Experience with Long Term Outcomes

OBJECTIVE

To review our experience in the management of paediatric urethral strictures with buccal mucosal graft urethroplasty and its long term outcomes.

METHODS

This was a retrospective analysis of a prospectively maintained data base between 2009-2019. Circumcised children with long segment urethral strictures (> 1.5 cm) were included. They were characterized as either peno-bulbar (PBS) or isolated bulbar strictures (IBS) based on a standardized protocol. All children underwent single stage dorsal onlay buccal mucosal graft urethroplasty by either the Kulkarni technique (PBS group) or the Barbagli technique (IBS group). All children were followed up at 3 months, then annually thereafter with flow rates at each visit. Success was defined as a flow rate > 10ml/sec with a bell-shaped curve and absence of need for any secondary procedures.

RESULTS

28 children underwent buccal mucosal graft uretheroplasty.16 children were diagnosed with PBS & 12 children with IBS. The median age was 7.5 years (2-17 years) in PBS and 5.5 years (3-10 years) in IBS. Iatrogenic injury was the commonest aetiology ie 71 % (20/28). Mean length of stricture was 4 cm (3-5.5 cm) in PBS and 2.5 cm (2-3.5 cm) in IBS. Median follow up was 96 months (24-120 months) in PBS and 90 months (36-120 months) in IBS. The success rate was 87.5% (14/16) in PBS and 83.3% (10/12) in IBS.

CONCLUSION

Single stage dorsal on lay buccal mucosal graft urethroplasty, ie Kulkarni and Barbagli techniques are safe and feasible in children with long segment urethral strictures with good long-term outcomes.

Anterior Urethral Strictures in Children: Disease Etiology and Comparative Effectiveness of Endoscopic Treatment vs. Open Surgical Reconstruction

Pediatric anterior urethral strictures are rare and recommendations regarding treatment strategies derive from small monocentric case series. In 2014, a collaborative effort of the Société Internationale d'Urologie and the International Consultation on Urological Diseases drafted the first systematic and evidence-based guideline for diagnosis and treatment of urethral strictures in children. Against this backdrop, we performed an updated literature review to provide a comprehensive summary of the available evidence and contemporary outcomes with a focus on comparative effectiveness of endoscopic treatment (dilation or urethrotomy) vs. open surgical reconstruction. Overall, 22 articles reporting on children with anterior urethral strictures were included into the review. Most strictures were iatrogenic (48%) and traumatic (34%), whereas congenital (13%), inflammatory (4%), or postinfectious strictures (1%) were rather rare. The cumulative success rate of endoscopic treatment and urethroplasty was 46% (range: 21-75; N = 334) and 84% (range: 25-100; N = 347), respectively. After stratifying patients according to urethroplasty technique, success rates were 82% (range: 25-100; N = 206) for excision and primary anastomosis, 94% (range: 75-100; N = 40) for graft augmentation, 97% (range: 87-100; N = 30) for flap urethroplasty, and 70% (one study; N = 20) for pull-through urethroplasty. In conclusion, endoscopic approaches are rather ineffective in the long-term and open surgical reconstruction via urethroplasty should be preferred to avoid multiple, repetitive interventions. Future research may involve multi-institutional, collaborative, and prospective studies, incorporating well-defined outcome criteria and assessing objective surgical endpoints as well as patient-reported functional outcomes.