Substitution urethroplasty for posterior urethral stenosis

Posterior urethral stenosis occurs commonly following traumatic urethral injury, treatment for prostatomegaly or prostate cancer, and pelvic radiation. Perineal reconstruction for posterior urethral stenosis can be performed via excisional urethroplasty with primary anastomosis, or via substitution urethroplasty with the use of buccal mucosa graft (BMG). This article provides a stepwise description and comprehensive review of our technique for posterior substitution urethroplasty. Helpful tips and recommendations regarding common pitfalls encountered perioperatively are also presented. Key maneuvers described include unilateral urethral mobilization, graft fixation using laparoscopic suturing devices, fibrin sealant, or a barbed-suture sewing machine, as well as the use of the RaViNi lighted urethral speculum to enhance urethral exposure. In addition to describing our technique and institutional outcomes, a brief and focused review of the literature is presented to support the utility of substitution urethroplasty in posterior urethral reconstruction. While there is a dearth of prospective data, retrospective studies from single-center and multi-institutional data report success rates for posterior substitution urethroplasty between 63% and 89%, with rates of de novo urinary incontinence ranging from 0% to 11%. Overall, substitution urethroplasty offers key advantages such as versatility and favorable rates of de novo stress urinary incontinence, making it preferable to excisional urethroplasty for posterior urethral reconstruction, when feasible.