Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

Abstract

Purpose: The treatment of urethral stenosis after a combination of prostatectomy and radiation therapy for prostate cancer is understudied. We evaluate the clinical and patient-related outcomes after dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) in men who underwent prostatectomy and radiation therapy.

Materials and methods: A multi-institutional, retrospective review of men with vesicourethral anastomotic stenosis or bulbomembranous urethral stricture disease after radical prostatectomy and radiation therapy from 8 institutions between 2013 to 2021 was performed. The primary outcomes were stenosis recurrence and development of de novo stress urinary incontinence. Secondary outcomes were surgical complications, changes in voiding, and patient-reported satisfaction.

Results: Forty-five men were treated with D-BMGU for stenosis following prostatectomy and radiation. There was a total of 7 recurrences. Median follow-up in patients without recurrence was 21 months (IQR 12-24). There were no incidents of de novo incontinence, 28 patients were incontinent pre- and postoperatively, and of the 6 patients managed with suprapubic catheter preoperatively, 4 were continent after repair. Following repair, men had significant improvement in postvoid residual, uroflow, International Prostate Symptom Score, and International Prostate Symptom Score quality-of-life domain. Overall satisfaction was +2 or better in 86.6% of men on the Global Response Assessment.

Conclusions: D-BMGU is a safe, feasible, and effective technique in patients with urethral stenosis after a combination of prostatectomy and radiation therapy. Although our findings suggest this technique may result in lower rates of de novo urinary incontinence compared to conventional urethral transection and excision techniques, head-to-head comparisons are needed.

Keywords: buccal mucosal urethroplasty; post-radiation strictures; reconstructive urology; salvage prostatectomy; vesicourethral anastomotic stenosis.

Graphical abstract

Figure 1.

A, Lateral dissection of urethra and dorsal urethrotomy. Dotted line indicates area to be excised. B, Intercrural tissue is excised anterior between 1- and 11-o’clock positions. C, Buccal mucosa is sutured to proximal apex of urethrotomy and quilted on corpora cavernosa. D, Intraoperative image after dorsolateral dissection and excision of stenotic region. Urethral mucosa is stained with methylene blue. A nasal speculum is placed in the urethra to aid in placement of apical stitches. Arrows show double-arm sutures placed apically ready for parachuting of the graft. E, Intraoperative image, after buccal mucosa graft is quilted dorsally and the medial graft-urethra running anastomosis has been completed. Urethral gorget is placed in the urethra to aid in visualization during quilting and anastomosis. F, Postoperative voiding cystourethrography at time of catheter removal. G, Preoperative voiding cystourethrography and retrograde urethrography in patient with recurrent stenosis following robotic-assisted laparoscopic prostatectomy and adjuvant external beam radiation therapy. Urethra is still patent at last follow-up, 96 months.

Figure 2.

Recurrence-free survival curve. There was a total of 7 events. The median time to recurrence is not defined as the probability of recurrence never reached 50%.