Urethroplasty for High Risk, Long Segment Urethral Strictures with Ventral Buccal Mucosa Graft and Gracilis Muscle Flap

Abstract

Long segment urethral strictures with a compromised graft bed and poor vascular supply are unfit for standard repair and at high risk for recurrence. We assessed the success of urethral reconstruction in these patients with a ventral buccal mucosa graft and gracilis muscle flap. We retrospectively reviewed the records of 1,039 patients who underwent urethroplasty at Lahey Hospital and Medical Center between 1999 and 2014. We identified 20 patients who underwent urethroplasty with a ventral buccal mucosa graft and a gracilis muscle flap graft bed. Stricture recurrence was defined as the inability to pass a 16Fr cystoscope. Mean stricture length was 8.2 cm (range 3.5 to 15). Strictures were located in the posterior urethra with or without involvement of the bulbar urethra in 50% of cases, and in the bulbomembranous urethra in 35%, the bulbar urethra in 10% and the proximal pendulous urethra in 5%. Stricture etiology was radiation therapy in 45% of cases, followed by an idiopathic cause in 20%, trauma in 15%, prostatectomy in 10%, and hypospadias failure and transurethral surgery in 5% each. Nine patients (45%) were previously treated with urethroplasty and 3 (15%) previously underwent UroLume® stent placement. Urethral reconstruction was successful in 16 cases (80%) at a mean followup of 40 months. One of the patients in whom treatment failed had an ileal loop, 2 had a suprapubic tube and urethral dilatation had been done in 1. Mean time to recurrence was 10 months (range 2 to 17). Postoperatively 5 patients (25%) had incontinence requiring an artificial urinary sphincter. Urethroplasty for high risk, long segment urethral strictures can be successfully performed with a ventral buccal mucosa graft and a gracilis muscle flap, avoiding urinary diversion in most patients.