Small intestinal submucosa viable for stricture repair

Düsseldorf, Germany-Reconstruction using commercially available porcine small intestinal submucosa as an onlay patch appears to be a reasonable alternative to buccal mucosa grafting for urethral stricture repair after failed endoscopic treatment, according to a recent study.

Researchers from Düsseldorf University, Düsseldorf, Germany presented their experience using this technique in a consecutive series of 49 patients treated between 2003 and 2011. All patients had failed at least one endoscopic urethrotomy, and they represented a heterogeneous group with respect to age and stricture length, location, and etiology. The small intestinal submucosa (SIS [Surgisis, Cook Medical, Bloomington, IN]) was used as a dorsal onlay patch in 38 cases and as a ventral onlay patch in 11, reported first author Lena von Seggern, MD, urology resident at Düsseldorf University.

During follow-up ranging from 0.4 to 95 months, the repair with SIS remained successful in 33 patients (67%). The remaining 16 patients developed recurrent stricture, typically at the anastomosis site, after a mean of 4.5 months (range, 1.2 to 19.5 months).

Outcomes of the patients with recurrent stricture showed that internal urethrotomy or salvage reconstruction with buccal mucosa was successful after failure of the SIS urethroplasty. Two patients with a stricture recurrence refused further surgery and were managed with urinary diversion by a suprapubic tube. The remaining 14 patients underwent revision by internal urethrotomy (nine cases), buccal mucosa grafting (four cases), or perineal urethrostomy (one case).

Excluding nine of the 49 patients who were lost to long-term follow-up, four who died for unrelated reasons, and the two patients who refused reoperation, the remaining 34 patients all remain recurrence-free.
“Urethral stricture repair after failure of endoscopic treatment remains a major challenge because of the high rate of recurrence. While implantation of a buccal mucosa graft is considered the current gold standard, that procedure is associated with added morbidity and operating time due to the need for harvesting the graft material,” said Dr. von Seggern.

“These issues are mitigated using small intestinal submucosa as the graft material. Based on what we consider encouraging results from this retrospective study, a prospective randomized trial comparing small intestinal submucosa with buccal mucosa for urethral stricture repair after failed endoscopic treatment is currently under way at our center.”

Procedure shortens OR time
“Reconstruction using small intestinal mucosa has advantages for shortening the OR time and avoiding harvesting of the buccal mucosa graft, for which the

positioning in the OR is something that older patients sometimes do not tolerate,” said senior author Peter Albers, MD, professor and chair of urology at Düsseldorf University. “However, even longer follow-up is needed to confirm the 67% success rate recorded in our study.”

The patients in the series had a mean age of 61 years and mean stricture length of 4.84 cm (range, 1-15 cm). The most common etiologies for the stricture were transurethral resection of the prostate (33%) and catheterization (18%). Stricture location was in the distal penis in six cases, bulbar penis in three, bulbarmembraneous in 37, and multilocular in three. The surgical technique involved penile degloving in cases of penile strictures, and a perineal incision was performed in men with bulbar strictures.

Comparisons between patients in whom urethroplasty with SIS was successful and those who developed recurrent stricture showed no significant differences with respect to age, stricture length, etiology, or whether the onlay patch was ventral or dorsal.

Findings were presented at the 2012 AUA annual meeting in Atlanta.UT