Elsevier

Urology

Volume 122, December 2018, Pages 169-173
Urology

Reconstructive Urology
Changing Trends in Reconstruction of Complex Anterior Urethral Strictures: From Skin Flap to Perineal Urethrostomy

https://doi.org/10.1016/j.urology.2018.08.009Get rights and content

Abstract

Objective

To evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade.

Methods

We retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management.

Results

Among 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%).

Conclusion

Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps.

Section snippets

Materials and Methods

We performed an institutional review board approved retrospective study of male patients undergoing complex urethral reconstruction for stricture by a single surgeon at our tertiary academic referral center between 2007 and 2017. All patients had symptomatic urethral stricture, characterized by obstructive voiding symptoms, urinary retention and/or recurrent urinary tract infections and diagnosed on retrograde urethrography and/or cystoscopy. Focal and uncomplicated strictures amenable to

Patient and Stricture Characteristics

Among 1129 urethral strictures undergoing reconstructive surgery, 403 complex strictures meeting inclusion criteria were analyzed (median length 4.5 cm) and are summarized in Table 1. Reconstruction was most commonly performed using BMG (247/403, 61.3%), followed by penile skin flap (87/403, 21.6%) and PU (77/403, 19.1%). Among the BMG cases, 70.4% were single-stage repairs (174/247), while two-stage repairs were less common (73/247, 29.6%).

Although median age overall was 53.2 years (standard

Discussion

Our reconstructive approach for complex urethral stricture has gradually changed over the last decade to reflect emerging evidence and refinements in technique. Although BMG continues at a stable rate, accounting for nearly two-thirds of complex cases, penile skin flap became less common and PU use rose dramatically. Successful outcome without need for additional intervention remained nearly universal following PU, compared to BMG and penile skin flap techniques, which were successful only

Conclusion

Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for complex strictures are markedly higher than those of grafts and flaps.

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Financial Disclosure: Dr. Allen Morey receives honoraria for being a guest lecturer/meeting participant for Boston Scientific. The remaining authors declare that they have no relevant financial interests.

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