Multistage urethroplasty yields high durable patency rate

Anterior urethral strictures associated with hypospadias repair or lichen sclerosus pose a surgical challenge, often necessitating a staged approach to repair, using oral mucosa grafts. In a Cleveland Clinic study presented yesterday, multistage urethroplasty with buccal mucosa led to a high rate of durable patency, associated with a low incidence of complications and revisions.

Editor's note: This article has been updated since its original publication to include additional study data and commentary from the author/presenter.

Orlando, FL-Anterior urethral strictures associated with hypospadias repair or lichen sclerosus pose a surgical challenge, often necessitating a staged approach to repair, using oral mucosa grafts. In a recent study, multistage urethroplasty with buccal mucosa led to a high rate of durable patency, associated with a low incidence of complications and revisions.

To date, 75 of 78 patients have been tubularized. A high patency rate resulted irrespective of etiology, which included complications following hypospadias repair, lichen sclerosus, combined etiology, trauma, and idiopathic recurrent stricture.

“In this difficult group of patients, we have shown that we can perform reconstruction with an excellent long-term patency rate, and in the majority of cases, we can complete the reconstruction with just two planned operations,” said first author Ryan Mori, MD, a urology fellow at Cleveland Clinic’s Glickman Urological and Kidney Institute.

During a mean follow-up of 12.5 months, the complication rate has been 19.2%, and 10.3% of the patients required revision procedures.

“Despite the level of difficulty associated with these cases, it is possible to have a low restricture rate. However, it has been shown that the revision rate can be very high. The procedure used to be called a two-staged approach, but the term ‘multistaged’ has become more common because as many as 50% to 60% of the patients require three or more operations to complete the repair,” said Dr. Mori, who worked on the study with Kenneth Angermeier, MD, and Hadley Wood, MD.

At the AUA annual meeting in Orlando, FL, Dr. Mori reported findings from a retrospective review of 78 staged urethroplasty procedures performed over a 12-year period. The series included long-segment, panurethral, and multifocal urethral strictures. Stricture length averaged 9 cm.

The patients had a mean age of 38.4 years (range, 8 to 66 years). Hypospadias failure accounted for 39 (50%) of the cases, followed by lichen sclerosus in 31 (39.7%), a combination of hypospadias and lichen sclerosus in three (3.8%), trauma in four (5.1%), and idiopathic recurrent stricture in four (5.1%).

Continue to the next page for more.

As a group, the men had an extensive treatment history, including prior interventions in 90% of the cases. A majority of the patients (52%) had prior reconstructive procedures, and 25% had undergone surgery two or more times. All of the previous reconstruction procedures involved the penile urethra.

In 29 cases (37.2%), multifocal or panurethral stricture required simultaneous single-stage repair of the bulbar urethra, and the disease was limited to the penile urethra in the remaining 49 men. Bilateral buccal grafts were required in 35 cases (44.9%).

Patency rate of over 90% achieved

The procedures have achieved a urethral patency rate of over 90%. The second stage is pending for two patients because of medical and socioeconomic reasons. The proportion of patients requiring more than two operations has been 14%, including preplanned three-stage procedures.

Dr. Mori reported that 12 patients had a total of 14 complications. Eight patients required revision, including two patients who required multiple revisions. The most frequent complications were urethro-cutaneous fistula in six patients, glanular dehiscence in five, postoperative bleeding and spraying stream in one patient each, and recurrent stricture in three. One patient who developed a fistula subsequently had recurrent stricture.UT