97 Flap or no flap in repair of urethral stricture

Abstract

Introduction: When recurrent strictures become troublesome to deal with endoscopically and excision and anastomotic repair is not possible, substitution urethroplasty employing various pedicle flaps repair is the treatment of choice. In the past, foreskin flap, penile skin and scrotal skin had been employed with varying success. Unfortunately with long term follow up all skin repairs have high degree of recurrent UTI, recurrent stricture, stone formation, lichen sclerosus changes at the flap and diverticulum formation. Buccal mucosal free patch graft repair has gained wide acceptance after early reporting by G Barbagli in its use as dorsal onlaid graft in early 90's. The author reported his early work back in 1998, modifying the dorsal onlaid graft to ventral graft attracted criticism. With long‐term follow up and recent reporting from the Barbagli unit using the dorsal onlaid graft, the result presented from our unit is comparable to other major units around the world with minimal complications.Result: Between 1996 and 2005, 126 patients had BM ventral onlaid graft urethroplasty for recurrent strictures. All patients tertiary referred had previous dilatation, optical urethrotomy and some had previous substitution urethroplasties. Before 1996, pedicle penile skin graft was commonly used in our unit to repair urethral stricture at the bulbar or penile urethra. Many scrotal onlaid grafts were revised. In this group of pedicle skin urethroplasties, UTI and postmicturition dribbling were commonly reported by pts. All pts after BM graft urethroplasty had follow up cystoscopy at 3 and 15 months to assess and calibrate their graft luminal size before discharge from the unit. The length of the graft ranged from 2.5 to 15 cm. The graft has been employed to repair stricture from meatus to proximal bulbar urethra. The recurrent stricture usually occurs at the junctional area, either proximal or distal graft anastomotic site. Recurrent stricture tends to occur in the three and six months period. Revision urethroplasty for recurrent stricture in this group of patients was 12%. Two out of 126 patients required complete revision of their graft due to significant shrinkage secondary to recurrent UTI. One pt developed urethral cutaneous fistula at the penile scrotal junction. Postmicturition dribbling secondary to diverticulum formation is not a feature in this group of pts and ejaculatory dysfunction has not been reported.Conclusion: Modified ventral onlaid BM graft urethroplasty has been proven a reliable long‐term solution to pts with recurrent stricture that require substitution urethral reconstruction. The use of pedicle skin flap substitution urethroplasty is limited due to high complication rate in long‐term follow up.