Management of complex anterior urethral strictures with multistage buccal mucosa graft reconstruction

To describe the indications and outcomes of salvage urethral reconstruction using the combination of urethrectomy and buccal graft replacement.

We retrospectively identified 91 consecutive patients who had undergone multistage urethral reconstruction from 2003 to 2009. The demographic and surgical outcomes data, including the need for first stage revision, pre- and postoperative urine flow rates, and reconstruction failure was collected for all patients.

Of the 91 patients, 51 (56%) subsequently underwent urethral tubularization, 17 (19%) were pending closure, and 23 (25%) had undergone the first stage only, with no plan for completion. The stricture etiology included hypospadias in 41 (45.1%), lichen sclerosus in 29 (31.9%), and a combination of the 2 in 10 (11%). Of the 91 patients, 54.9% had panurethral disease, with the remaining involving varying lengths of the anterior urethra. The mean follow-up was 15 months (range 12-69). A total of 17 patients (18.7%) required revision of their first stage, with 4 requiring ≥2 repairs. Seven patients (7.7%) required revision of their second stage, with 2 undergoing multiple revisions. The urine flow rates increased on average from 6.7 mL/s preoperatively to 21.5 mL/s postoperatively (P <.00001). In 9 patients (9.9%) reconstruction failed, and they required scheduled balloon dilation or a chronic indwelling catheter to maintain urethral patency.

Urethrectomy with salvage reconstruction using buccal mucosal grafts in a staged fashion is the optimal option for complex anterior urethral stricture resolution in these challenging patients. Surgical revision of the first or second stage could be required in up to 25% of challenging patients. Despite the high complexity and severity of the urethral stricture burden, a 90% success rate was achieved.