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Substitution Urethroplasty Of Complex And Long-Segment Urethral Strictures: A Rationale For Procedure Selection

March 19, 2017

UroToday- A recent report from Y-M Xu and colleagues from Shanghai, China describes the rationale used for management decisions in the treatment of men with long-segment and complex anterior urethral strictures.

Lengthy urethral strictures require substitution urethroplasty using free grafts, local pedicled skin flaps or a combination of these materials. There has not been an universally accepted procedure for the management of these complex strictures. In this report, the authors reviewed 65 cases of complex urethral strictures and attempted to identify criteria for procedure selection based on their results.

The study group consisted of 65 patients with a mean stricture length of 10.8 cm that was present for a period of 4.9 years. The etiology of stricture was traumatic in 46 patients, urethritis in 5, iatrogenic injury with infection in 6, and failed hypospadias repairs in 8. The patients had undergone a mean of 2.5 prior unsuccessful repairs or repeated urethral dilations. The site of stricture was penile urethra or from penile urethra to the bulbar or membranous urethra.

Three techniques of repair were utilized. Prior to 2000, patients underwent one-stage pedicled flap urethroplasty, bladder mucosal urethroplasty, and staged Johanson's urethroplasty. Since 2000, buccal mucosa or colonic mucosa became the first choice for patients who lacked adequate penile skin for repair. One-stage mucosal repairs of a tubed colonic grafts were used in 28 patients (mean stricture length 13.9 cm), dorsal buccal mucosa onlays were utilized in 12 (mean stricture length 8.83 cm), and a tubed bladder mucosa graft in 3 patients (mean stricture length 8.4 cm). Penile fasciocutaneous flaps were utilized in 14 patients (mean length 8.72 cm) and scrotal island flaps were used in 3 patients. In five patients with a mean stricture length of 10.2 cm, a staged Johanson repair was utilized.

Analysis of the results with a mean follow-up of 4.8 years showed an overall success rate in 76.92% (50 of 65 cases). Complications developed in 23% of cases including restenosis, fistula and chordee. After analysis of the results, the authors have made some conclusions about treatment choices for the management of these complex strictures. The vascularized penile/preputial flap has become their first choice when possible for the one-stage repair of penile strictures. Buccal mucosa or colonic mucosa has become their first choice for patients who have had multiple penile surgeries resulting in a shortage of penile skin. Colonic mucosa grafts are the first choice for patients with pan-urethral strictures or for strictures involving multiple portions of the urethra. The authors have abandoned the use of the scrotal island flap and the two-stage Johanson urethroplasty.

Xu YM, Qiao Y, Sa YL, Wu DL, Zhang XR, Zhang J, Gu BJ, Jin SB, Palminteri E

Eur. Urology. 51(4):1093-99, April 2007.

Reported by UroToday Contributing Editor: Michael J. Metro, M.D

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