Long anterior urethral stricture: Reconstruction by dorsally quilted penile skin flap

Anterior Urethroplasty for the Management of Urethral Strictures in Males: A Systematic Review

OBJECTIVE

To identify the currently utilised techniques of anterior urethroplasty described in literature for treatment of urethral strictures, assess the effectiveness of the identified techniques based on re-stricture and complication rates, evaluate, and suggest treatment options based on current evidence for urethral strictures at different locations and of different lengths.

METHODS

A systematic review of the MEDLINE, EMBASE, Scopus and Cochrane Library databases from conception up to September 2020 was performed. Primary outcomes included success rates measured via re-stricture rates and the post-operative maximum urinary flow rate (Qmax). Secondary outcomes included patient reported complication rates.

RESULTS

A total of 52 papers, including 7 RCTs, met the inclusion criteria. Forty studies described the use of free graft urethroplasty with a median success rate of 86.5% (IQR = 8.1). The best outcomes were found in dorsal onlay buccal mucosa grafting in the penile urethra (86.6%). Twelve described the use of pedicled flap urethroplasty with a median success rate of 76% (IQR = 14.4). Excision and Primary Anastomosis results were reported in 5 studies and showed an overall highest success rate of 89.7% (IQR = 7.0) but involved the shortest strictures of median lengths of 2.1 cm (IQR = 0.48).

CONCLUSION

Graft urethroplasty showed optimal outcomes when utilised in penile and bulbar strictures, with dorsal onlay buccal mucosa grafting presenting with the largest evidence base and best outcomes overall. Flap urethroplasty had the highest success rates in panurethral and bulbar strictures, while anastomotic urethroplasty had the greatest success in bulbar and penobulbar strictures.

Contemporary analysis of management of isolated pendulous urethral strictures using pedicled skin flap urethroplasty repair

OBJECTIVES

To evaluate contemporary outcomes of urethroplasty employing a pedicled skin flap for isolated pendulous urethral strictures.

SUBJECTS/PATIENTS

Inclusion of males > 18 years of age with isolated pendulous urethral strictures treated between 1996 and 2012.

RESULTS

A total of 81 patients with isolated pendulous urethral stricture were identified. Twenty-eight patients underwent repair with a pedicled skin flap during the study period. The median age of the patients treated with a pedicled skin flap was 47 years old (range 21-74). The etiology of the strictures was considered to be idiopathic in 10 patients (35.7%), iatrogenic in 9 patients (32.1%), as a complication of prior hypospadias repair in 6 patients (21.4%), infectious in 2 patients (7.1%), and traumatic in 1 patient (3.6%). The median follow-up was 27 months (range 1-214). Urethroplasty success was noted in 19/21 patients (90.5%). Urethral stricture recurrence occurred in 2 of the 21 patients (9.5%).

CONCLUSIONS

The pedicled skin flap repair for pendulous urethral strictures remains a durable and safe technique in patients without LS.

Penile fasciocutaneous flap urethroplasty for the reconstruction of pediatric long anterior urethral stricture

BACKGROUND

Though pediatric urethral stricture is an uncommon urological problem, it is a challenging urological one. The causative factors are iatrogenic, traumatic, and inflammatory. In the current study, the authors report their experience of the treatment of pediatric long anterior urethral stricture using penile circular fasciocutaneous flap.

PATIENTS AND METHODS

The study included 23 pediatric patients who had long anterior urethral strictures, which were repaired using circular penile fasciocutaneous flap. The flap was elevated through a subcoronal circumferential incision and then it was split ventrally. The strictured portion of the urethra was sharply incised ventrally, extending to 1 cm into normal urethra. The flap was sutured to the urethral plate over silicone catheter of suitable size, which was removed after 3 weeks. The follow-up was scheduled every 3 months for the first year and then yearly thereafter.

RESULTS

The urethroplasty was successful in 20 cases (86.96%). There were two cases complicated by stricture recurrence, which was managed by visual internal urethrotomy. Fistula formation was reported in one case and was repaired by simple excision and closure. Penile skin necrosis was reported in only one patient and was managed by frequent dressing.

DISCUSSION

During the last five decades, there was a substantial advancement in the reconstruction of long or complex anterior strictures due to the use of grafts and flaps. During pediatric urethral stricture repair, particular attention must be paid to the differences between adults and children anatomy, e.g. the small urethral lumen and tissue delicateness. McAninch introduced the reconstruction of complex anterior urethral strictures utilizing circular penile fasciocutaneous flap. The technique of penile fasciocutaneous flap urethroplasty takes long time and requires meticulous dissection. Therefore, it should be restricted for long or complex anterior urethra strictures. Success rate in this study was 86.96%, which is in the same league as that reported in literature as regard adults penile fasciocutaneous flap urethroplasty. Whitson et al. reported success rates of 84% and 79% in the 5th and 10th years, respectively. In another study, Kim et al. revealed a success rate of 68.9%. In this study, complications incidence was 21.6%, which is consistent with reported incidence of complications of adults penile fasciocutaneous flap urethroplasty (8%-20%).

CONCLUSION

According to the outcomes of this study, penile fasciocutaneous flap urethroplasty is a reasonable modality for the reconstruction of long anterior urethral stricture in pediatric patients especially after circumcision.

Histopathological characteristics of buccal mucosa transplants in humans after engraftment to the urethra: a prospective study

PURPOSE

Histopathological changes in buccal mucosa transplants after engraftment to the urethra and exposure to urine remain nebulous. We investigated histopathological changes in buccal mucosa transplants integrated into the urethra in humans.

MATERIALS AND METHODS

We prospectively evaluated 22 patients with recurrent urethral stricture after buccal mucosa urethroplasty between November 2012 and October 2013. All patients underwent repeat buccal mucosa urethroplasty performed by a single surgeon. Intraoperatively we harvested a sample of the integrated buccal mucosa transplant previously engrafted to the urethra, a sample of healthy urethra, a sample of freshly harvested buccal mucosa from the contralateral inner cheek and a sample of fibrotic tissue from the area of the current stricture. A dedicated uropathologist performed meticulous histopathological examination of all tissue samples using hematoxylin and eosin staining. Preoperative clinical data were also collected on all patients.

RESULTS

The mean interval from previous to current buccal mucosa urethroplasty was 22.2 months (range 4.1 to 76.0). Mean stricture length at repeat urethroplasty was 52.7 mm (range 30.0 to 70.0). Histopathological characteristics of the integrated buccal mucosa transplants were completely preserved in all patients, consisting of thick sheets of stratified nonkeratinized squamous epithelium with a stratum spinosum. Transplants were not partially or entirely overgrown with urothelium.

CONCLUSIONS

Buccal mucosa transplants retain their histopathological characteristics and are not overgrown with urothelium after urethral engraftment and urine exposure in humans. These findings may explain the superiority of buccal mucosa transplants on the outcome of substitution urethroplasty compared to that of other materials.