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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 6  |  Page : 794-800

The success of dorsal onlay buccal mucosal graft urethroplasty in challenging urethral stricture cases after multiple failed urethrotomies


1 Department of Urology, Suleyman Demirel University School of Medicine, Isparta, Turkey
2 Department of Urology, Aydın State Hospital, Aydın, Turkey

Date of Submission20-Apr-2021
Date of Acceptance18-Feb-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. S A Ozturk
Assistant Professor of Urology, Suleyman Demirel University School of Medicine, Department of Urology, Isparta
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1440_21

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   Abstract 


Background: Urethroplasty is the gold standard treatment procedure for male patients with urethral stricture and is becoming increasingly popular among urologists worldwide. Procedure success rates have risen with increased experience. Aims: Here we aimed to examine the results of urethroplasty in challenging cases of urethral stricture and its effect on sexual function. Patients and Methods: Data were collected retrospectively from the patients who had undergone urethroplasty after multiple failed direct vision internal urethrotomy (DVIUs) from 2017 to 2020. All patients were monitored for a minimum of 12 months. Outcomes of urethroplasty were analyzed according to stricture location, length, and the number of prior DVIUs. Penile length and sensation, erectile, and ejaculatory function of the patients were evaluated pre- and postoperatively. Results: The patient cohort consisted of 36 males with a mean age of 63 ± 3.2 years. The most prevalent stricture etiology was iatrogenic (83%). Patients who underwent three or more DVIUs before urethroplasty and stricture length >4 cm were included in the analysis. Accordingly, the overall success rate was 83% (30/36). When the success rate and the IIEF5 scores were assessed separately, there was no significant relationship between the number of DVIUs (P > 0.05). Similarly, no significant relationship was also found with the stricture length (P > 0.05). Conclusion: Appropriate and correctly applied surgical technique does not impair sexual activity, even in patients with severe urethral stricture, regardless of the length or location of the stricture and the number of prior endoscopic procedures.

Keywords: Urethral stricture, urethral stricture length, urethroplasty


How to cite this article:
Ozturk S A, Guzel A, Ergun O. The success of dorsal onlay buccal mucosal graft urethroplasty in challenging urethral stricture cases after multiple failed urethrotomies. Niger J Clin Pract 2022;25:794-800

How to cite this URL:
Ozturk S A, Guzel A, Ergun O. The success of dorsal onlay buccal mucosal graft urethroplasty in challenging urethral stricture cases after multiple failed urethrotomies. Niger J Clin Pract [serial online] 2022 [cited 2022 Jul 6];25:794-800. Available from: https://www.njcponline.com/text.asp?2022/25/6/794/347602




   Introduction Top


Urethral stricture is defined as the narrowing or loss of distensibility of the urethral lumen, based on fibrosis and inflammation of the corpus spongiosum and epithelium.[1],[2] Stricture could exist in any part of the urethra, from the external meatus to the bladder. The urethral stricture prevalence is roughly 0.6%–0.9%.[3] Endoscopic management and urethroplasty are the cornerstones of treatment options for urethral stricture. Currently, urologists prefer endoscopic procedures to urethroplasty as the learning curve is shorter, more practical, and can be performed under local anesthesia.

The recurrence rate of urethral strictures varies between 20% and 80%, depending on the location, length, number of strictures, and surgeries.[4] The impact of length, location, number of strictures, and previously performed direct vision internal urethrotomy (DVIU) on urethroplasty outcomes is controversial. De la Rosette et al.[5] indicated that the highest proportion of recurrence was reported for those who underwent more than 3 DVIUs within a short time. Roehrborn and McConnell[6] demonstrated a twofold failure rate when patients had previously received treatment (dilation or surgical repair) for stricture or when urine was contaminated preoperatively despite antibiotic coverage. Kessler et al.[7] suggested that the probability of urethroplasty failure was higher in patients who had already experienced urethral stent placement (HR 3.69, 95% CI 1.27 to 10.8) and two or more DVIUs (HR 2.25, 95% CI 1.05 to 4.8). Barbagli et al.[8],[9] concluded that urethroplasty's long-term outcome was not affected in bulbar strictures treated by previously failed DVIUs.

Conflicting findings were also documented after urethroplasty about erectile and sexual functions. Critical aspects that may influence erectile functions are etiology, surgical technique, location and length of stricture, penile curvature or shortening, and ejaculatory disorders.[10],[11],[12],[13] Briefly, erectile dysfunction (ED) may result from both the etiology or treatment of stricture.

When surgeons encounter a patient with long-segment urethral stricture recurrence after several unsuccessful DVIUs, they confront daunting issues regarding the treatment choice, success rates, and sexual functions with a distinct lack of reports on this area of research. The findings are challenging to compare due to various patient populations, treatment groups, and measurement procedures. On the other hand, as urethroplasty becomes more widespread, articles published about its effects on sexual dysfunction increase.[12],[14] Therefore, we ought to assess the degree of sexual dysfunction, which may be caused by urethroplasties, such as erectile dysfunction, penile shortening, curvature, and decreasing penile sensation.

Here we have only included complicated cases in our study design. These challenging cases had at least three failed DVIUs and at least 5-cm urethral stricture segments. This research aimed to examine the success rates of urethroplasty in challenging urethral stricture patient cohorts and its effects on sexual function.


   Subjects and Methods Top


After obtaining the institutional ethics committee approval (77/2021), data from 42 males who had undergone urethroplasty after multiple failed DVIUs for long segment urethral stricture between January 2017 and December 2020 were identified by a prospectively collected database. In this research, only patients with multiple failed DVIUs (≥3) and long segment urethral strictures (>4 cm) were included. The data were reviewed in a retrospective manner. All patients had follow-ups for a minimum of 12 months.

All urethral stricture segments lied from the bulbomembranous to the penile urethra. Challenging urethral stricture cases were defined as a long urethral stricture (>4 cm) that began from the bulbomembranous segment and multiple previous failed DVIUs (3 or more) for stricture repair. The study patient cohorts preoperative median Qmax <6 mL/sn and five of them had suprapubic tube. The exclusion criteria were female gender, pediatric patients, uncontrolled diabetes mellitus, hematologic, liver or kidney dysfunction, lichen sclerosis, bladder neck strictures, short strictures (≤4 cm), incomplete follow-up period (<12 months), previous hypospadias repairment, and patients with a previous open urethral surgery. After the beginning of the study, the patients who had incomplete data or un-followed were excluded. The flowchart of the study is shown in [Figure 1].
Figure 1: The flowchart of the study

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The primary outcome of our research was postoperative failure-free survival in challenging urethral stricture cases, with the detection of effectiveness for the dorsal onlay buccal urethroplasty graft (DBMGU) method. Our secondary aims were to determine significant predictors for treatment failure and the influence of urethroplasty on sexual function.

Urethroplasty operations were performed by the same surgeon. Demographic data, medical history, etiology, smoking, comorbidities, and previous treatment failures were recorded. Retrograde urethrography, voiding cystourethrography, and cystoscopy were implemented to identify the diagnosis, length, number, and localization of strictures.

Preoperative urinalysis and urine cultures were controlled. Urine culture results confirmed the correct antibiotics were administered. Patients were not operated on until sterile urine was verified. The voiding patterns and maximal flow rate (Qmax) were evaluated by uroflowmetry, and ultrasonography was used for postvoid residual urine volume (PVR).

Patient recorded results were evaluated using validated questionnaires and direct patient interviews. The International Prostate Symptom Score (IPSS) and Quality of Life Score (IPSS-QoL) questionnaires were used to determine LUTS and quality of life in patients with urethral stricture. The five-item edition of the International Index of Erectile Function (IIEF-5) and the Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD) questionnaire forms were used to evaluate sexual activity. All patients were questioned about the existence of a suprapubic tube and prior dilatations and penis sensation changes. Also, patient penile length, Qmax, PVR, IIEF, MSHQ-EjD, IPSS, and IPSS-QoL scores were compared pre- and postoperatively.

Treatment failure was defined as either being Qmax <12 mL/s or requiring intervention, such as urethral dilation or urethroplasty during the follow-up period.

Surgical technique

The DBMGU technique described by Barbagli et al.[15] was chosen as the procedure of urethroplasty. We favored buccal mucosa as a graft over other types of extra-genital free grafts due to its properties.

Follow-up

Patients were usually followed with 16 Fr silicone catheters for 3 weeks and discharged with low-dose quinolone during the postoperative period. Patients were followed at 4-month intervals for the first 2 years and then once a year. Uroflowmetry and bladder ultrasound were performed at each control. Cystoscopy and retrograde urethrography were not used routinely during follow-up. If any subjective complaints or the Qmax, PVR, and IPSS results of the patients during the postoperative follow-up were doubtful for recurrence, endoscopic and radiographic evaluations were performed.

Statistical analysis

The ratio of the surgery success at long segment urethral stricture rate was 0.70 stated in the literature.[16] The effect size was calculated as d = 0.13, and considering the power as 80% and the type-I error as 0.05, the minimum sample size was calculated as 33. The study was completed with 36 patients satisfying the inclusion criteria in a planned period. Continuous variables were presented as mean ± SD (standard deviation) or median (min-max), whereas categorical data were presented as the number of cases and percentages. The paired t-test was applied for the comparison of preoperative and postoperative continuous variables after the surgical repair. Wilcoxon's sign rank test was used to evaluate preoperative and postoperative patient-reported survey results such as IIEF, IPSS, IPSS-QoL, and MSHQ-EjD. A Kaplan–Meier survival curve was plotted to determine stricture-free survival. Data were evaluated using IBM SPSS Statistics version 17.0 software (IBM Corporation, Armonk, NY, USA), with a P value <0.05 considered statistically significant.


   Results Top


The demographic and stricture characteristics of patients who met the research criteria and urethroplasty outcomes were analyzed. Forty-two male patients whose data were evaluated and who completed the eligibility criteria were included in the analysis. Patients who underwent three or more DVIUs before urethroplasty and strictures longer than 4 cm were included in the study. Six males with no routine follow-up or having missing data were omitted from the study.

The final study cohort consisted of a total of 36 patients. Demographic details and stricture characteristics of urethroplasty patients are presented in [Table 1]. The most common stricture etiology was iatrogenic (83%) and endoscopic interventions (47.2%). Seventeen patients (47.2%) had comorbidities. All patients had undergone various DVIUs before urethroplasty, and some patients had a maximum of 7 DVIUs. Also, prior dilations were performed in 16 patients (44.4%), and a suprapubic tube was applied to 5 of the 36 patients (13.9%) before urethroplasty. The stricture mean length was 7.3 ± 2.9 cm. The median follow-up time was 27 months (IQR 12–48). Accordingly, the overall success rate was 83% (30/36). Patient mean recurrence-free survival time was 49.31 months (95% CI 43.8–54.8), while the median failure time was 11.5 months [Figure 2]. The presence of comorbidity did not affect treatment failure.
Table 1: Demographic characteristics of patients who underwent bulbar urethroplasty using the dorsal approach

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Figure 2: Kaplan–Meier survival plot depicting the stricture-free survival analysis of urethroplasty for anterior urethral strictures

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The median surgical time was 118.5 ± 37.17 min (IQR 75–220). Blood transfusions were not required. The majority of patients were discharged on a postoperative day two (61.2%). There were no complications within the first 90 days following surgery, except for two patients with Clavien-Dindo grade 2 complications (UTIs requiring oral antibiotics). No patient experienced fistula, penile curvature, graft loss, or oral complications at any time during follow-up.

Compared to pre- and postoperative surgical and patient-reported results at the end of the 2-year follow-up period, mean Qmax increased from 4.48 ± 2.4 mL/s to 21.81 ± 9.2 mL/s (P ≤ 0.0001), whereas mean PVR decreased significantly from 83 mL to 26 mL (P ≤ 0.0001). Patient median IPSS (from 21 to 7) and median IPSS-QOL (from 5 to 1) score significantly improved (P < 0.0001). However, when the pre- and postoperative median IIEF5, MSHQ-EjD scores and mean penile length of the patients were compared, there was no significant difference [Table 2].
Table 2: Surgical and patient-reported outcomes

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As our patients had three or more DVIUs before urethroplasty, a Pearson correlation was used to evaluate a possible effect of the number of DVIUs on patient erectile function (EF) and the success of urethroplasty. However, the changes in the IIEF5 score and the success rate were not statistically significant (r = −0.32, P = 0.112 and r = −0.19, P = 0.527). We categorized patients into four groups, as shown in [Table 3], to assess the relationship between the length of the stricture and the IIEF5 score and treatment failure in all patients undergoing surgery. The differences in the IIEF5 score between these four groups were analyzed by using one-way ANOVA and were not statistically significant before and after urethroplasty (P = 0.084, P = 0.461, respectively). However, there was no significant association between the stricture length and the success rate (r = −0.24, P = 0.617).
Table 3: Comparison of preoperative and postoperative IEFF scores between stricture lengths

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Twenty-six patients (72%) reported that there were no changes in penile sensation after surgery. Five of the remaining ten patients (14%) reported a change in penile sensation after surgery, while five patients (14%) stated they were unstable. The difference between patients was not significant (P = 0.072) [Figure 3].
Figure 3: Changes in penis sensation after urethroplasty

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   Discussion Top


Urethral strictures disrupt patient quality of life and may also lead to significant problems such as acute/chronic kidney failure and urosepsis, which threaten patient health according to the duration of untreated strictures.[17] Iatrogenic factors have a dominant place in etiology and play a critical role. Parallel to the increasing number of endoscopic urethral interventions, this role becomes more evident.[18] Minimally invasive transurethral interventions are widely used in many clinics for urethral strictures. Unfortunately, due to the high recurrence and failure rates and poor curative results, patients have low confidence in minimally invasive treatment.[19],[20]

Urethroplasty is another treatment option for urethral stricture and is considered a surgical technique for which most urologists and clinics have little experience.[19] However, interest in urethroplasty surgery is growing among urologists worldwide. This interest leads to an increase in experience and, thus, the chances of patients achieving this treatment increase. This study showed that if an experienced surgeon performs the urethroplasty, high success rates can be achieved even in challenging cases and that the urethroplasty procedure will not adversely affect the sexual function of the patients.

Various techniques have been described according to different stricture regions for open urethroplasty.[21] Several studies reported varying success rates for different urethroplasty techniques.[16],[19] Yalçınkaya and Kartal[19] performed different urethroplasty techniques in their series of 244 patients, and the success rate was reported as 81% in 84 DBMGU patients. From a series of 174 patients who underwent different urethroplasty techniques, Claassen et al.[16] reported that the success rate of DBMGU was 71.9%. In this study, unlike the above studies, we achieved a higher success rate of 83% in 36 challenging urethral stricture patients who underwent DBMGU.

Some studies have reported that the lengths of the stricture and the number of DVIUs affect urethroplasty's success.[7],[16],[19],[22] Claassen et al.[16] reported that stricture length was significantly associated with urethroplasty failure. Success rate decreased to 71% in strictures longer than 4 cm. Yalçınkaya and Kartal[19] reported that there is a negative correlation between stricture length and treatment success. Similarly, they emphasized that two or more DVIU interventions had a significant adverse effect on urethroplasty. The present study demonstrated no relationship between the treatment failure and stricture length and the number of DVIUs. In contrast to the above studies, we believe that the length of the stricture and the number of DVIUs do not negatively affect the urethroplasty's success.

Several studies reported that the stricture regions also affected the success of urethroplasty.[16],[23] Breyer et al.[23] showed that strictures located in the penile urethra have a higher recurrence rate after urethroplasty. In contrast, Claassen et al.[16] reported that the stricture location did not affect treatment success. As shown in our study, successful results can be obtained by experienced surgeons, even in challenging patients with strictures starting from the bulbomembranous and extending to the penile urethra.

The causes of erectile dysfunction (ED) in men with urethral stricture has not been definitively identified. Nevertheless, some patients and urologists are concerned that urethroplasty can induce ED and result in penile shortening and curvature, which may influence postoperative sexual function and treatment choices.[24] The authors emphasized that surgeries on the anterior urethra region do not lead to ED.[13],[25] A recent meta-analysis of 2323 anterior urethroplasty patients indicated that the stricture region did not provoke de novo ED rates alone.[25] Similarly, this study revealed that urethroplasty does not cause a predisposition to ED. Barbagli et al.[13] recorded penile sensation changes in 18% and ejaculation problems in nearly 23% of patients. Whereas Kałużny et al.[24] reported that the most critical risk factor for developing penile curvature after urethroplasty is the stricture location. They specified that the etiology, urethroplasty technique used, length of stricture, and the number of prior DVIUs had no significant effect on the postoperative penile anatomy, penile sensation, and erectile function. While our research involved patients who had undergone urethroplasty for challenging urethral strictures, only 14% complained about postoperative penile sensory changes, and none of the patients developed postoperative penile curvature. However, the stricture characteristics and the number of previous DVIUs had no significant effect on erectile functions.

The limitations of the present study are that it has a single-center design and a retrospective nature, as well as the presence of a limited number of patients. Although the inclusion of the various lengths of strictures created heterogeneity in our study, high success rates in challenging cases were obtained. We demonstrate that urethroplasty performed by an experienced surgeon does not affect sexual function, even in the case of complicated patients. We believe our results will guide urologists who may consider working on urethral strictures.


   Conclusion Top


Urethroplasty is a successful procedure for the management of male patients with challenging urethral strictures. Appropriate and correctly applied surgical techniques should not significantly impair sexual function, regardless of the stricture characteristics and the number of previous endoscopic interventions. To improve success rates and protect sexual function, a surgeon must be experienced with the urethroplasty procedure used.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Mundy AR, Andrich DE. Urethral trauma. Part I: Introduction, history, anatomy, pathology, assessment and emergency management. BJU Int 2011;108:310–27.  Back to cited text no. 1
    
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Grimes MD, Tesdahl BA, Schubbe M, Dahmoush L, Pearlman AM, Kreder KJ, et al. Histopathology of anterior urethral strictures: Towards a better understanding of stricture pathophysiology. J Urol 2019;202:748-56.  Back to cited text no. 2
    
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Wong SS, Aboumarzouk OM, Narahari R, O'Riordan A, Pickard R. Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men. Cochrane Database Syst Rev 2012;12:CD006934. doi: 10.1002/14651858.CD006934.pub3.  Back to cited text no. 4
    
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de la Rosette JJ, de Vries JD, Lock MT, Debruyne FM. Urethroplasty using the pedicled island flap technique in complicated urethral strictures. J Urol 1991;146:40–2.  Back to cited text no. 5
    
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Kessler TM, Schreiter F, Kralidis G, Heitz M, Olianas R, Fisch M. Long-term results of surgery for urethral stricture: A statistical analysis. J Urol 2003;170:840–4.  Back to cited text no. 7
    
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Barbagli G, Palminteri E, Bartoletti R, Selli C, Rizzo M. Long-term results of anterior and posterior urethroplasty with actuarial evaluation of the success rates. J Urol 1997;158:1380–2.  Back to cited text no. 8
    
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Barbagli G, Palminteri E, Lazzeri M, Guazzoni G, Turini D. Long-term outcome of urethroplasty after failed urethrotomy versus primary repair. J Urol 2001;165:1918–9.  Back to cited text no. 9
    
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Erickson BA, Granieri MA, Meeks JJ, Cashy JP, Gonzalez CM. Prospective analysis of erectile dysfunction after anterior urethroplasty: Incidence and recovery of function. J Urol 2010;183:657–61.  Back to cited text no. 12
    
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Palminteri E, Berdondini E, De Nunzio C, Bozzini G, Maruccia S, Scoffone C, et al. The impact of ventral oral graft bulbar urethroplasty on sexual life. Urology 2013;81:891–8.  Back to cited text no. 14
    
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Barbagli G, Palminteri E, Guazzoni G, Cavalcanti A. Bulbar urethroplasty using the dorsal approach: Current techniques. Int Braz J Urol 2003;29:155–61.  Back to cited text no. 15
    
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Claassen FM, Mutambirwa SBA, Potgieter L, Botes L, Kotze HF, Smit FE. Outcome determinants of urethroplasty in the management of inflammatory anterior urethral strictures. South Afr Med J Suid-Afr Tydskr Vir Geneeskd 2019;109:947–51.  Back to cited text no. 16
    
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Yalçınkaya F, Kartal I. Critical analysis of urethroplasty for male anterior urethral stricture: A single-center experience. World J Urol 2020;38:2313–9.  Back to cited text no. 19
    
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Akyüz M, Tokuç E, Özsoy E, Koca O, Kanberoğlu H, Öztürk M, et al. Characteristics of the urethroplasty and our approach-Experience in patients with urethral stricture. Turk J Urol 2019;45:307–11.  Back to cited text no. 21
    
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Breyer BN, McAninch JW, Whitson JM, Eisenberg ML, Mehdizadeh JF, Myers JB, et al. Multivariate analysis of risk factors for long-term urethroplasty outcome. J Urol 2010;183:613–7.  Back to cited text no. 23
    
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Kałużny A, Krukowski J, Matuszewski M. Erectile dysfunction after urethroplasty. Cent Eur J Urol 2019;72:402–7.  Back to cited text no. 24
    
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Blaschko SD, Sanford MT, Cinman NM, McAninch JW, Breyer BN. De novo erectile dysfunction after anterior urethroplasty: A systematic review and meta-analysis. BJU Int 2013;112:655–63.  Back to cited text no. 25
    


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