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Abstract
Summary
Of the numerous techniques evolved to treat anterior urethral strictures, tissue transfer techniques appear to be the most successful with an increasing role in urethroplasty, specially in long segment anterior urethral strictures.
Buccal mucosa graft and penile skin flap are commonly used as tissue transfer techniques with better results than other free grafts or pedicled flaps.
In this study, we retrospectively studied both techniques separately and in combination among a large number of patients with anterior urethral strictures (276 patients) who were categorized according the used technique into three groups, buccal mucosa graft group, penile skin flap group and combined group.
Our patients who were from different age groups had a higher incidence of idiopathic strictures specially in the graft group with no association between etiology and age.
Most of the cases had single urethral strictures. Stricture length was nearly the same in graft and flap groups, while patients who received combined tissue transfer had a longer strictures.
Bulbar strictures were the majority in the graft group while penile strictures were the majority in the flap group. Combined graft and flap technique was only used in cases with strictures affecting both bulbar and penile urethral portions.
Penile urethra was found to be more affected by congenital, inflammatory and iatrogenic strictures than bulbar urethra, while bulbar urethra was obviously more affected by traumatic and idiopathic strictures.
Despite that there was no difference in preoperative retention among the three groups, patients of the combined group showed marked increased incidence of preoperative diversion. This may be due to the fact that not all patients with preoperative retention needed urethral diversion.
Most patients in this study (80%) had history of chronic stricture disease and previous urethral instrumentation in the form of dilatations or internal urethrotomy. In addition, 74 patients had failed open urethroplasties either in the form of anastomotic end-to-end urethroplasty or substitution urethroplasty.
Postoperative follow-up ranged from one month to more than twelve years with a mean follow-up period of 17.8 months. We had 138 patients (50%) with follow-up period more than 6 months, 98 patients (36%) with follow-up more than one year. and 33 patients (12%) with more than 4 years of follow-up.
We had a very minimal donor site complication rate, either in the oral cavity (2.8%) or the penile skin (2.2%). Position-related complications were also minimal (4%) with higher incidence among patients of the combined group may be due to the complexity of this operation requiring more operative time in the lithotomy position. Erectile dysfunction appeared in (4.3%) with a higher incidence in the flap group. Other complications such as urethral fistula, hematoma, postvoid dribbling and urinary tract infection had a similar incidence in all three groups.
Recurrent strictures occurred mostly in the first year. Sixty-two patients representing 22.5% of our patients suffered from recurrent strictures with significant difference between the three groups. Combined group had the highest rate with 38.1% followed by penile skin flap group with 26.3%, while buccal mucosa graft group had the lowest rate with 15.2%.
No specific relation was found between recurrence and the etiology of the stricture. We had relatively comparable incidence of recurrence in penile urethral strictures (22%) and bulbar urethral strictures (17%) with a significantly higher incidence of recurrence in strictures involving both penile and bulbar urethral portions, being longer in length and more complicated in reconstruction technique.
Success rate was 80% in this study. The highest success rate was in the BMG group with 88% and the lowest was in the combined group with 62%. Penile skin flap group had a success rate of 75%. There was a statistically significant difference between the three groups.
While there was no difference between ventral and dorsal placement of the tissue used, we found that success rate of onlay transfer (80%) is significantly higher than that of tubularized transfer (57%).