Single-stage urethroplasty with buccal mucosal inlay graft for stricture caused by balanitis xerotica obliterans in boys: Outcomes in the medium term

Abstract

Balanitis xerotica obliterans (BXO) is a common condition that can affect the foreskin, glans, meatus, and urethra, and rarely can also involve urethra leading to stricture. Numerous procedures have been suggested to treat urethral stricture secondary to BXO but these have had variable results. We describe the first prospective study of a single stage buccal mucosal inlay grafting in children with urethral strictures resistant to existing remedies. We treated five boys with resistant urethral strictures secondary to BXO with a single stage buccal mucosal inlay graft (BMIG, Figure). Uroflowmetry was performed both pre- and post-operatively. Functional outcome was the prime measure determining success. All the boys had a successful functional outcome and all expressed satisfaction with cosmetic outcome as well. Uroflow parameters improved remarkably, with maximum and mean urinary flow rates significantly improved from 4.2mL/s to 26mL/s (p=0.0002) and from 1.6mL/s to 12.2mL/s (p=0.003), respectively. Median follow-up was 34 months (range 30-42 months). This paper is the first to describe the successful use of buccal mucosal inlay grafts to treat refractory BXO stricture in children. Various surgical techniques have been proposed particularly in adults including single vs. staged procedures, preputial and post auricular grafts, circular mucosal buccal grafts, as well as double mucosal grafts placed both ventrally and dorsally. All of these procedures are not without problems, and had variable results and outcome. Most of the procedures have been described in adult urethra and are not suitable for paediatric small calibre urethra. Our technique of dorsal inlay graft gives a robust structure to the distal urethra avoiding diverticula, pooling or urine spraying and can be placed onto proximal urethra as well. We have not seen recurrence of BXO in our buccal grafts, which is reported in other grafts from prepuce and post auricular grafts. The number of patients presented in our study is limited, nonetheless an excellent result in all our cases makes this a compelling approach to manage BXO urethral strictures. An early intervention in such cases is paramount to convert a salvage operation to a pre-emptive procedure. A single stage buccal mucosal inlay grafting in children with BXO stricture can offer an excellent outcome.