Introduction

Figure 1. Cystography with evidence of penobulbar stricture (arrow).

Figure 2. Creation of elliptical area for the dorsal inlay graft.

Figure 3. Buccal mucosa graft harvested and quilted over the dorsal plate.

Figure 4. Second buccal mucosa graft sutured laterally to the mucosal margin of the urethral plate.

Figure 5. Spongioplasty.

Figure 6. Postoperative uroflowmetry. Q indicates flow rate; Qmax, maximum flow rate; T, time; V, voided volume.

Urethral stricture is a pathology often complex and difficult to manage. Various techniques have been developed to treat it, ranging from primary anastomosis to tissue flaps and grafts.¹ Traditionally, short-segment obliterative bulbar strictures (<2 cm) are managed by excision and end-to-end anastomosis urethroplasty. However, bulbar urethral strictures (>2 cm) that are not amenable to end-to-end anastomosis urethroplasty can be managed by augmentation urethroplasty.² Currently, the preferred tissue for grafts is the oral mucosa due to its excellent physical characteristics and because harvesting is simple and with low rates of morbidity.¹ A combined dorsal and ventral onlay augmentation urethroplasty technique was described by Palminteri et al for bulbar urethral reconstruction.³

Clinical Case

In 2021, a 67-year-old male with a history of open prostatectomy presented with a recurrence of urinary symptoms associated with an epididymo-orchitis episode and urinary retention during the early postoperative period. In emergency care and given the impossibility of passing a urethral catheter, transurethral cystoscopy and cystography were performed which documented a penobulbar narrowing of 90% of the lumen, making it necessary to perform a suprapubic cystostomy. Single-graft urethroplasty was performed in December 2021 with early reappearance of the symptoms and a new episode of urinary retention with a transurethral cystoscopy and cystography that showed reappearance of the narrowing, making it necessary to perform a suprapubic cystostomy again (Figure 1). A double-graft urethroplasty was performed evidencing the previous graft with contracture and occlusion of 100% of the urethral lumen, with significant associated spongiofibrosis and a defect with a total length of 4 cm.

Surgical Technique

The operative procedure was performed under general anesthesia with nasotracheal intubation. Retrograde and anterograde urethroscopy was performed with a flexible cystoscope to assess the urethral stricture and its length. Buccal mucosa graft (BMG) was used for augmentation of the urethra. BMG was harvested from the inner cheek and the donor site was closed with interrupted polyglactin sutures (3/0). A midline perineal incision was created. The bulbospongiosus muscle was identified and incised in the midline to expose the bulbar urethra. Ventral sagittal urethrotomy was performed opening the urethra and the stricture and extended 1 cm distally and proximally to the normal urethral lumen. The dorsal urethral plate was incised with a scalpel in the midline until the tunica albuginea of the corpora cavernosa. An elliptical area was created for the dorsal inlay graft (Figure 2), and the BMG was harvested and quilted in this area over the dorsal urethral plate with running polydioxanone (5/0) sutures (Figure 3). Subsequent to the dorsal urethral augmentation, the second BMG was sutured laterally to the left mucosal margin of the urethral plate with a running polydioxanone (5/0) suture. The catheter was inserted, and finally the graft was rotated and sutured laterally to the right mucosal margin (Figure 4). Finally, spongioplasty was performed with running polydioxanone (4/0) suture (Figure 5).

Follow-up and Outcomes

Catheter removal was done 3 weeks after surgery. The patient was followed with AUA Symptom Score, uroflowmetry, and ultrasound with post-void residual urine every 3 months for the first year and every 6 months thereafter without evidence of recurrence of emptying symptoms to date (Figure 6).

Discussion

Several surgical techniques have been described to treat bulbar urethral strictures based on stricture length. Traditionally, short urethral strictures are treated with excision and end-to-end anastomosis, whereas longer strictures are repaired by patch graft urethroplasty, preferably using BMG. The graft can be placed dorsally or ventrally by using dorsal or ventral urethrotomy approaches.⁴ The advantages of BMG, compared to penile skin flaps or other kind of grafts such as genital/extragenital skin or bladder/intestinal mucosae, include a cosmetically superior incision, decreased operative time, low harvest morbidity, and better histological characteristics of the graft.³ One of the reasons for surgical failure is retraction of the graft, which may occur around 30% of the grafted tissue. In more extensive cases of stenosis, when the caliber of the urethra is narrower, a graft of greater diameter is required, hence the risk of stenosis is greater. Double grafts have been used to maximize success in these cases.¹ The technique described by Palminteri et al offers the possibility of a wide urethral lumen with good urinary outcomes and preservation of sexual function.³ This technique has the following advantages: (1) the ventral approach is technically easy, (2) there is no mobilization or rotation of the urethra, which preserves the vascular erectile function, (3) preservation of the urethral plate with watertight urethral mucosa and graft augmentation can be performed with a wide urethral lumen, and (4) both dorsal and ventral grafting can be performed depending on the narrow urethral plate.² In conclusion, the double-face augmentation urethroplasty is a feasible and versatile technique that can be considered in many circumstances, including long and complex strictures and failed urethroplasty, with satisfactory outcomes.⁵