Single‐stage segmental urethral replacement using combined ventral onlay fasciocutaneous flap with dorsal onlay buccal grafting for long segment strictures

OBJECTIVE To present our experience with repairing long-segment urethralstrictures in a single-stage using a combined tissue-transfer technique. PATIENTS AND METHODS In all, 14 men underwent urethroplasty where a segment of urethra was completely replaced using a dorsal onlay buccal mucosa graft and a ventral onlay fasciocutaneous flap in a single stage. Primary success was defined as an open urethra at >6 months follow-up with no need for additional surgical intervention. Secondary success was defined as the need for a single postoperative endoscopic procedure before stricture stabilization. Failure was the need for multiple endoscopic procedures, repeat urethroplasty, urinary diversion or intermittent dilatation. RESULTS The mean (SD) stricture length was 9.75 (4.6) cm. The mean (SD) neourethral length was 5.4 (2.7) cm. Stricture location was penile/bulbar in 12 men, and bulbar alone in two. Primary success was achieved in nine of the 14 men at a median (range) follow-up of 2.5 (0.5 – 9.43) years. The mean (SD) time to recurrence in the five initial failures was 340 (376) days. Secondary success was achieved in two men after a single endoscopic procedure for an overall success in 11 of 14 men. Patients that recurred had longer strictures (12.8 vs 8.7 cm, P = 0.04) than initial successes, but neourethral lengths were similar (6.2 vs 5.1 cm, P = 0.5). In all, three of the 14 men failed, two of whom required a repeat urethroplasty. CONCLUSIONS Our initial outcomes were favourable using the combined tissue-transfer technique for segmental urethral replacement with initial and secondary success rates similar to those reported for two-stage repairs. This technique is not suitable for all patients as it requires healthy penile skin, but appears to be effective when a single-stage repair is desirable. Keywords: urethral stricture, fasciocutaneous flap, buccal mucosa, single-stage INTRODUCTION Long-segment pendulous urethral stricture disease is a very difficult surgical problem. This is especially true in men where part of the existing urethral plate is unsalvageable. In this group, standard reconstructive techniques, using either ventral fasciocutaneous penile flaps [1] or dorsal buccal mucosa grafts (BMGs) [2] are not always possible, as these techniques require the graft or flap to be anastomosed to the healthy edges of an existing urethral plate. Options in this group then become either tubularization of the graft or flap in a single-stage, which has been shown to have uniformly poor outcomes [1,3], or resorting to a multi-stage procedure using the Johansson principles [4]. While the later technique has been shown to be successful in some men, it renders these patients with a hypospadiac urethra for at least 6 months [5]. Additionally, while this technique is often described as a two-stage repair, a large percentage of men undergoing this type of repair will either require multiple additional revisions [3], or will simply choose to not undergo their second stage at all [6]. The limiting factor in single-stage procedures for these severe strictures in which a complete segment of urethra must be replaced, seems to be the lack of a reliable blood supply that is capable of providing for the entire neourethra [3]. In our attempt to solve this problem, in select men we have performed a single-stage operation using both a dorsal onlay of buccal mucosa and a ventral distal penile fasciocutaneous flap, which when combined, can completely replace a diseased segment of urethra. This repair incorporates two separate and independent sources of blood supply to the neourethra and we herein present our initial experience with the technique.