Endoscopic buccal urethroplasty for membranous stricture disease

Abstract

Membranous urethral strictures pose a challenging problem for reconstructive urologists given the difficult location and the impact on continence. Our study aims to expand on the surgical technique, outcomes, and complications of endoscopic buccal mucosal urethroplasty (EBMGU) in the treatment of membranous stricture disease. A single institution retrospective review of patients treated with EBMGU for management of membranous stricture disease between February 2022 and December 2024 was conducted. Patients with obliterative strictures and radiation were also included. Data collected included patient demographics, prior treatments, uroflow, post void residual volumes, stricture characteristics, intraoperative details, and complications. Patients with at least a 4-month follow-up cystoscopy were included. Surgical success was defined as the ability to pass a 17-Fr cystoscope into the bladder at the time of 4-month follow-up. Twenty-eight men are included in this study. Median age was 71 years (range, 46-85 years), and median follow-up was 8 months (range, 4-27 months). Twenty-four (85%) had prior radiation, and 4 had a history of pelvic fracture urethral injury (PFUI). Five (17%) patients had an obliterative stricture disease, 26 (93%) patients had at least one prior intervention, 23 (82%) were patent on 4-month cystoscopy, and these patients had a history of radiation. All patients with a history of PFUI were patent on a 4-month cystoscopy. Sixteen (57%) have gone on to receive an artificial urinary sphincter (AUS), 3 (10%) patients required cystectomy with urinary diversion. One for refractory hematuria due to radiation cystitis, one for refractory symptomatic bladder neck necrosis with sloughing, and one for delayed urosymphyseal fistula in the setting of extensive radionecrosis of the bladder neck. EBMGU is an effective option for management of membranous stricture disease in radiated patients in the short term. Four-month success rates were 82%. More than half of the patients went on to successful AUS placement.

Keywords: Urethroplasty; buccal mucosal graft; endoscopic; urethral stricture.

Figure 1

Management of obliterative membranous urethral stricture. (A) Needle and wire are passed retrograde under direct visualization with a cystoscope placed antegrade. (B) Balloon dilation of the stricture over wire. (C) Placement of antegrade stay suture at the bladder neck using the RD180. (D) Following graft deployment, quilting of the graft to the bed using SecureStrap.

Figure 2

Comparison of membranous stricture before and after endoscopic buccal urethroplasty. (A) Membranous stricture prior to endoscopic buccal urethroplasty. (B) Cystoscopy at 4 months post op with patent urethra and well incorporated graft along the dorsal membranous urethra.

Figure 3

The presence of urethral radionecrosis negatively impacts graft incorporation. In patients with radionecrosis and mucosal sloughing of the urethra (A), we are less likely to recommend endoscopic buccal urethroplasty due to the poor vascularity of this tissue. Excellent ventral graft uptake is seen when radionecrosis is absent (B).