Anastomotic Urethroplasty is Associated with a Lower Risk of Stricture Recurrence Compared with Buccal Mucosa Graft...

The preferred treatment of bulbomembranous urethral stenosis (BMUS) after prostate cancer radiotherapy remains unclear. The purpose of this study was to examine the association of surgical technique and outcomes after urethroplasty for radiation-induced BMUS.

From January 2001 to September 2024, a review of patients undergoing posterior urethroplasty for BMUS at 2 centers was performed. The primary outcome was stricture recurrence defined as stricture < 16Fr confirmed on cystoscopy. Secondary outcomes included 90-day complications (Clavien ≥ 2), patient-reported satisfaction, de novo erectile dysfunction, or incontinence. Cox regression was used to evaluate variables associated with stricture recurrence, and Fisher exact test was used for secondary outcomes.

Two hundred twelve patients with radiation-induced BMUS were reconstructed with either anastomotic urethroplasty (163) or buccal mucosal graft (BMG) (49). Median stenosis length was 2.0 cm (IQR 2.0-3.0); median follow-up for patients without recurrence was 97 months (IQR 52-144); and etiology was brachytherapy (46%), external beam radiotherapy (45%), or combination (9.0%). On Cox regression, BMG urethroplasty was independently associated with stricture recurrence (HR 3.43, 95% CI 1.03-11.47; P = .046), whereas patient age (P = .3), stenosis length (P = .1), diabetes (P = .7), smoking (P = .5), obesity (P = .6), and prior endoscopic treatments (P = .6) were not. For BMG urethroplasty, the estimated cumulative risk of stricture recurrence at 1, 2, and 10 years was 17%, 18%, and 20% compared with 3.3%, 5.0%, and 6.8%, respectively, for anastomotic urethroplasty (log-rank P = .01). Techniques did not differ in complications (10% vs 4.1%; P = .3), satisfaction (90% vs 88%; P = .6), erectile dysfunction (15% vs 8.2%; P = .2), or incontinence (18% vs 18%; P = 1.0).

When technically feasible, anastomotic urethroplasty is associated with a lower risk of stricture recurrence compared with onlay with buccal mucosa when reconstructing radiation-induced bulbomembranous urethral stenosis without a higher risk of adverse events.