Abstract
(1) Background: To critically evaluate dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for posterior urethral stenosis repair following transurethral resection and other endoscopic prostate procedures. (2) Methods: A retrospective multi-institutional review of patients with membranous or bulbomembranous urethral stenosis for whom treatment with DOBMGU was conducted after receipt of prostate endoscopic procedures. Baseline data, peri-operative care, post-operative care and patient-reported outcomes were analyzed. The primary outcomes were procedural failure and development of de novo stress urinary incontinence (SUI). The secondary outcomes were changes in voiding, sexual function and patient satisfaction. (3) Results: A total of 107 men with a mean age of 69 ± 9.5 years and stenosis length of 3.5 ± 1.8 cm were included. Prior endoscopic procedures among participants were 47 patients (44%) with monopolar TURP, 33 (30.8%) with bipolar TURP, 16 (15%) with Greenlight laser, 9 (8.4%) with Holmium laser enucleation and 2 (1.9%) with bladder neck incision. At a mean follow-up time of 59.3 ± 45.1 months, stenosis recurred in 10 patients (9.35%). Multivariate analysis confirmed that postoperative complications (OR 12.5; p = 0.009), history of radiation (OR 8.3; p = 0.016) and ≥2 dilatations before urethroplasty (OR 8.3; p = 0.032) were independent predictors of recurrence. Only one patient (0.9%) developed de novo SUI. Patients experienced significant improvement in PVR (128 to 60 cc; p = 0.001), Uroflow (6.2 to 16.8 cc/s; p = 0.001), SHIM (11.5 to 11.7; p = 0.028), IPSS (20 to 7.7; p < 0.001) and QoL (4.4 to 1.7; p < 0.001), and 87 cases (81.3%) reported a GRA of + 2 or better. (4) Conclusions: DOBMGU is an effective and safe option for patients with posterior urethral stenosis following TURP and other prostate endoscopic procedures. This non-transecting approach minimizes external urinary sphincter manipulation, thus limiting postoperative risk of SUI or erectile dysfunction.
Highlights
Transurethral resection of the prostate (TURP) has been the gold standard surgical treatment for lower urinary tract symptoms due to benign prostatic obstruction (BPO) [1,2]
None of these approaches are devoid of complications, and the development of urethral stricture along with bladder neck contracture may appear during follow-up [4]
Due to the proximity of the rhabdosphincter and cavernous nerves to the membranous urethra, reconstruction of membranous stenosis implies a risk of urinary incontinence and erectile dysfunction, and this concern is greater in patients with previous TURP in which the bladder neck and the internal sphincteric mechanism may be disrupted [17,18]
Summary
Transurethral resection of the prostate (TURP) has been the gold standard surgical treatment for lower urinary tract symptoms due to benign prostatic obstruction (BPO) [1,2]. Other endoscopic approaches, such as KTP laser vaporization and Ho:YAG laser enucleation of the prostate (HoLEP), are proving to be good alternatives to TURP, and transurethral incision of the prostate remains a valid option in the case of small prostate size without a median lobe [3]. None of these approaches are devoid of complications, and the development of urethral stricture along with bladder neck contracture may appear during follow-up [4]. Many etiologic factors are likely involved, including false passage, mechanical trauma from the large caliber of the instruments utilized, longer duration of surgery and insufficient isolation of the electrical current [6,7].
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