Elsevier

Urology

Volume 85, Issue 6, June 2015, Pages 1483-1488
Urology

Reconstructive Urology
A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures

https://doi.org/10.1016/j.urology.2015.01.041Get rights and content

Objective

To evaluate the treatment options and surgical outcomes of long-segment urethral strictures—a review of the largest, international, multi-institutional series.

Methods

A retrospective review was performed of patients treated with strictures ≥8 cm at 8 international centers. Endpoints analyzed included surgical complications and recurrence.

Results

Four hundred sixty-six patients were identified. Treatment intervals ranged from December 27, 1984 to November 9, 2013. Dorsal onlay buccal mucosal graft (BMG) was the most common procedure (223, 47.9%); others included first- and second-stage Johanson urethroplasty (162 [34.8%] and 56 [12%], respectively), fasciocutaneous (FC) flaps (8, 1.7%), and a combination flap and graft (17, 3.6%). Overall success was achieved in 361 patients (77.5%) with a mean follow-up of 20 months. Second-stage Johanson urethroplasty was found to have a higher recurrence rate compared with that of 1-stage BMG urethroplasty (35.7% vs 17.5%, respectively; P <.01). This was also true in cases of lichen sclerosus (14.0% vs 47.8%, respectively; P <.01). Otherwise, success rates were similar. Urethroplasties performed with FC flaps had a higher complication rate compared with those without (32% vs 14%, respectively; P = .02). Prior dilation or urethrotomy, higher number of prior dilations or urethrotomies, abnormal voiding cystourethrogram, and skin grafts all portend a higher recurrence rate. On logistic regression analysis, only second-stage Johanson had an increased odds ratio of recurrence compared with that of BMG (2.82 [1.41-5.86]).

Conclusion

Long-segment strictures can be treated with high success rates in experienced hands. BMG was more successful than second-stage Johanson urethroplasty. FC flaps, although successful, had high complication rates.

Section snippets

Methods

After obtaining institutional review board approval, a retrospective, international, multi-institutional review was performed of patients who were treated with at least 1 urethroplasty for a nonobliterated stricture ≥8 cm with at least 1 year of follow-up and with known recurrence status. Exclusion criteria included obliterative strictures, a stricture treated with an anastomotic urethroplasty (in an augmented fashion), scrotal skin, smooth intestine submucosa augmentation, or a history of

Results

Four hundred eighty-two patients were evaluated from December 1984 to November 2013. Four hundred sixty-six patients met inclusion criteria for analysis. Of the excluded patients, 3 had small intestine submucosal augments, 8 had an augmented anastomotic urethroplasty, 1 had previous radiation, 1 was treated with scrotal skin, and finally 3 had no available information regarding recurrence status.

Mean age was 51.3 years (range, 16-82 years); average follow-up was 20 months (range, 12-344

Comment

This study has several important findings that are readily applicable for reconstructive urologists.

  • (1)

    Ventral or dorsal buccal mucosal urethroplasty appears more successful than the 2-stage Johanson urethroplasty (18% failure vs 36% failure, respectively; odds ratio, 2.87).

  • (2)

    BMG, when used in LS patients treated with 2-stage Johanson urethroplasty, resulted in far fewer recurrences than when BMG is not used (14% recurrence rate vs 48%, respectively). BMG was also superior to skin grafts (16% vs

Conclusion

One-stage repairs with BMG offer an excellent option for patients with long segment and panurethral stricture disease. In cases with obliterative or absent urethral plate, a 2-stage Johanson urethroplasty with BMG offers a viable alternative. In cases of LS, 1-stage BMG has better outcomes than a 2-stage repair. If BMGs are not available, FC flaps offer similar success; however, these are associated with higher rates of complications. Skin grafts should be avoided, unless no alternatives exist.

References (24)

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    In addition, 19% of men required a revision of their first-stage urethroplasty [54]. The options for surgical reconstruction are various and often include combinations of different techniques or grafts (Table 6) other than oral mucosa graft (OMG) [53]. The patency rates are usually lower than in shorter reconstructions (Supplementary Table 4).

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Financial Disclosure: Kenneth W. Angermeier is a paid consultant to American Medical Systems. The remaining authors declare that they have no relevant financial interests.

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