Iatrogenic urethral strictures following pull-through procedures: buccal mucosa inlay repair

Damage to the male urethra following pelvic surgery for anorectal malformations (ARM) is a well known problem, usually seen in boys with rectourethral fistulas. Urethral strictures located in the posterior urethra are difficult to treat because surgical exposure of the posterior urethra is difficult and conventional reconstructive procedures do not consistently yield good results. Free buccal mucosa grafts placed either ventrally or dorsally have shown superior results to other techniques. We herein describe our technique of urethral reconstruction in three boys with iatrogenic strictures of the posterior urethra following pull-through procedures.

Exposure of the posterior urethra was achieved by a posterior sagittal approach. In a boy with Hirschsprung's disease a trans-anorectal approach was used and in two boys with ARM the anus and rectum were fully mobilized. The posterior urethra was opened in the midline ventrally and the stricture was incised dorsally. A free buccal mucosal graft was placed and sutured into the incision. The urethra was closed dorsally and the bowel reconstructed.

Mean age at operation was 22 months (9-39 months) and mean follow up was 17 months (6-22 months). No patient developed complications due to the operation. Stenting of the urethra was done with a silicone Foley catheter for 14 days. All three boys were able to void spontaneously following the operation and were continent for urine. No urinary tract problems developed. Both boys with ARM had colostomies which were closed 6 weeks later. Both are socially continent for feces. The boy with Hirschsprung's disease had no colostomy for the procedure and is fully continent.

The buccal mucosa inlay repair procedure via a posterior sagittal approach yields good results with low morbidity. Exposure of the posterior urethra is excellent with this approach, which we thus recommend in boys with posterior urethral strictures. However, the surgeon should be very experienced with anorectal surgery and the posterior sagittal approach.