Urethroplasty for high risk, long segment urethral strictures with ventral buccal mucosa graft and gracilis muscle flap.

PURPOSE: Long segment urethral strictures with a compromised graft bed and poor vascular supply are unfit for standard repair and at high risk for recurrence. We assessed the success of urethral reconstruction in these patients with a ventral buccal mucosa graft and gracilis muscle flap.

MATERIALS AND METHODS: We retrospectively reviewed the records of 1,039 patients who underwent urethroplasty at Lahey Hospital and Medical Center between 1999 and 2014. We identified 20 patients who underwent urethroplasty with a ventral buccal mucosa graft and a gracilis muscle flap graft bed. Stricture recurrence was defined as the inability to pass a 16Fr cystoscope.

RESULTS: Mean stricture length was 8.2 cm (range 3.5 to 15). Strictures were located in the posterior urethra with or without involvement of the bulbar urethra in 50% of cases, and in the bulbomembranous urethra in 35%, the bulbar urethra in 10% and the proximal pendulous urethra in 5%. Stricture etiology was radiation therapy in 45% of cases, followed by an idiopathic cause in 20%, trauma in 15%, prostatectomy in 10%, and hypospadias failure and transurethral surgery in 5% each. Nine patients (45%) were previously treated with urethroplasty and 3 (15%) previously underwent UroLume® stent placement. Urethral reconstruction was successful in 16 cases (80%) at a mean followup of 40 months. One of the patients in whom treatment failed had an ileal loop, 2 had a suprapubic tube and urethral dilatation had been done in 1. Mean time to recurrence was 10 months (range 2 to 17). Postoperatively 5 patients (25%) had incontinence requiring an artificial urinary sphincter.

CONCLUSIONS: Urethroplasty for high risk, long segment urethral strictures can be successfully performed with a ventral buccal mucosa graft and a gracilis muscle flap, avoiding urinary diversion in most patients.