Experience Shows Staged Buccal Graft Urethroplasty is Effective

By Kenneth Angermeier, MD; Hadley Wood, MD; and Ryan Mori, MD

Although the majority of urethral strictures are repaired in a single operation, a two-stage approach is preferred in some situations. For example:

• Patients with recurrent stricture following hypospadias surgery often have insufficient genital skin for flap reconstruction, and may not have adequate dartos fascia to reliably support one-stage urethral reconstruction using a graft. In this setting, staged buccal graft urethroplasty has emerged as a reliable form of repair.
• A second group of patients who may benefit from this approach are those with anterior urethral strictures related to lichen sclerosus (LS), which are often long and associated with significant spongiofibrosis. This group is known to have a higher stricture recurrence rate following surgery compared with other stricture etiologies. Although success with a one-stage operation has been reported, a staged technique has been shown to be a reliable form of reconstruction, especially in the presence of inflammatory obliteration of the glanular and distal penile urethra.

Previous reports of staged buccal graft urethroplasty have occasionally described the need for three or more operations to complete the reconstruction, and in some series, relatively low rates of progression to urethral tubularization have been noted, with patients retaining a proximal urethrostomy.

These findings prompted us to review our experience with staged buccal graft urethroplasty during the past 10 years. We identified 78 men who have undergone the procedure, with hypospadias-related stricture present in 53 percent, LS in 40 percent and other conditions in 7 percent. Stricture was limited to the penile urethra in 63 percent of patients, and was multifocal or panurethral involving both the penile and bulbar urethra in 37 percent.

Details of the Surgery

The surgical procedure is initiated by opening the urethra from the distal end of the stricture (typically at the urethral meatus) and continuing the urethrotomy incision into healthy wide-caliber urethra for a distance of 1 to 1.5 cm.

Figure 1. (A) First stage: Ventral urethrotomy and incision of glans penis. (B) Exposure for buccal mucosa harvest. (C) Buccal graft sutured and quilted onto recipient bed.

At that site, a urethrostomy is created using adjacent penile or scrotal skin for part of the circumference when necessary. In the case of a particularly dense or obliterated area of stricture, which seems to occur most often within the glanular and distal penile urethra in men with LS, this segment maybe completely excised.

Dartos fascia may be mobilized to cover the tunica albuginea adjacent to the urethral plate if needed to provide a good graft bed. Buccal mucosa is then harvested, either unilaterally or bilaterally, and sutured and quilted into place along either side of the urethral plate or across the midline in place of the urethra. A bolster dressing is applied for five days to promote graft take, and a urethral catheter is left indwelling for two to three weeks.

Figure 2. Bolster secured in place to immobilize graft for five days.

Second-stage tubularization is carried out when the graft has healed and softened, usually four to six months later. We strive for a healed urethral plate of approximately 3 cm in width to allow for adequate final diameter of the urethral lumen and to minimize the chance of recurrent stricture. The patient is informed that additional oral mucosa (either lingual or buccal) may be harvested to complete the repair if the plate is insufficient in a particular area. The urethra is closed and additional tissue layers are mobilized and brought together as available, or a tunica vaginalis flap may be raised to cover the repair if the dartos is inadequate. The repair is stented for three weeks, and the patient is then monitored in routine fashion.

Figure 3. (A) Second stage: Well-healed buccal graft and urethral plate prior to procedure. (B) Tubularization of the urethra. (C) Immediate postoperative appearance.

Postoperative Complications and Conclusion

Postoperative results following staged buccal graft urethroplasty have been quite good. Recurrent stricture or urethrocutaneous fistula requiring intervention developed in 4 percent and 5 percent of patients, respectively (one patient had both). In five patients (6.4 percent), the glans closure opened to the level of the corona, and three requested a surgical revision as a result.

More than 95 percent of our patients returned for second stage tubularization. Ninety-six percent of repairs were completed in two operations, with those needing a planned additional procedure having had a history of obesity and buried penis.

In summary, staged buccal graft urethroplasty is an effective procedure for patients with difficult anterior urethral strictures, particularly those with a history of hypospadias repair or LS. Although some patients in these two categories may be candidates for reconstruction in a single operation, one should not hesitate to use a staged approach if the status of local tissues is questionable, due to the high rate of success and acceptable morbidity.

Dr. Angermeier is a staff member of Cleveland Clinic Glickman Urological & Kidney Institute’s Department of Urology and Director of the Center for Genitourinary Reconstruction. Dr. Wood is a staff member of the Urological & Kidney Institute’s Center for Genitourinary Reconstruction and an Assistant Professor of Surgery at Cleveland Clinic Lerner College of Medicine. Dr. Mori is a former genitourinary reconstruction and prosthetic surgery fellow in the Center for Genitourinary Reconstruction.