14 DORSAL VS VENTRAL ONLAY FOR SINGLE STAGE BULBAR URETHROPLASTY

Abstract

INTRODUCTION AND OBJECTIVES: Buccal mucosa is widely accepted as a graft material for bulbar urethroplasty. However, the ideal location for the graft remains contentious. In an effort to determine whether outcomes differ based on whether the graft is placed ventrally or dorsally, we retrospectively reviewed our experience with buccal mucosal grafts for bulbar urethral strictures. METHODS: This was a retrospective, single-center study of all single-stage bulbar urethroplasties performed from 2001-2011 by two surgeons in which buccal mucosa was used as an onlay graft. Our primary objective was to assess whether outcomes differed based on a ventral or dorsal position. Failure was defined as the need for endoscopic or open revision of the reconstruction, or placement of a suprapubic catheter for urinary retention. RESULTS: A total of 105 patients were reviewed; 41 underwent dorsal onlay, and 63 underwent ventral onlay. Median age was 39. Stricture etiology included trauma (37), instrumentation (8), infection (5), radiation (4), hypospadias (3), BXO (1), and was unknown in 46. Prior urethroplasty had been performed in 14 (13.3%), one DVIU had been performed in 31 (29.5%), more than one DVIU in 40 (38.1%), and only 17 (16.2%) patients had not undergone a DVIU or a urethroplasty prior to the onlay. There was no significant difference between the ventral and dorsal onlay cohorts in terms of etiology, number of prior DVIUs, prior urethroplasty, or prior procedures. A greater number of patients in the dorsal onlay group underwent an augmented anastomosis than in the ventral onlay group (41.5% vs 14.3%, p 0.002). Mean follow-up was 17.9 months. There were 7 failures (17.1%) in the dorsal onlay group and 12 failures in the ventral onlay group (19.1%). Median time to failure was 8.5 months in the dorsal onlay group and 15 months in the ventral onlay group (p 0.13). Neither type of onlay nor presence of prior urethroplasty, prior DVIU, prior procedure, or augmented anastomosis was predictive of failure. CONCLUSIONS: In this retrospective review of substitution urethroplasties in a heterogenous group of patients, there is no evidence to suggest that dorsal or ventral onlay of buccal mucosa is inherently superior. Intra-operative decision-making is likely to be important, and prospective studies are necessary to further evaluate the long-term efficacy of each of these approaches.