JU INSIGHT Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Postprostatectomy, Postradiation Stenosis Patients

By: Joshua Sterling, MD, Yale School of Medicine, New Haven, Connecticut; SUNY Upstate Medical University, Syracuse, New York; Jay Simhan, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Brian J. Flynn, MD, University of Colorado School of Medicine, Aurora; Paul Rusilko, DO, FACS, University of Pittsburgh, Pennsylvania; Wagner A. França, MD, Hospital do Servidor Público Estadual de São Paulo, Brazil; Erick A. Ramirez, MD, Hospital Angeles Mocel, Mexico City, Mexico; Javier C. Angulo, MD, Universidad Europea de Madrid, Spain; Francisco E. Martins, MD, University of Lisbon, Hospital of Santa Maria, Portugal; Hiren V. Patel, MD, PhD, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Margaret Higgins, MD, University of Colorado School of Medicine, Aurora; Daniel Swerdloff, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Dmitriy Nikolavsky, MD, SUNY Upstate Medical University, Syracuse, New York | Posted on: 19 Apr 2024

Sterling J, Simhan J, Flynn BJ, et al. Multi-institutional outcomes of dorsal onlay buccal mucosal graft urethroplasty in patients with postprostatectomy, postradiation anastomotic stenosis. J Urol. 2024;211(4):596-604.

Study Need and Importance

Radiation and surgery remain the primary treatments for intermediate- and high-risk localized prostate cancer. Anastomotic stenosis is a known sequela of these treatments with varying incidence rates depending on surgical approach and type of radiation. Endoscopic attempts to manage these patients are universally ineffective, and excisional urethroplasty techniques for the repair of postradiation anastomotic stenosis have substantial rates of new stress urinary incontinence (SUI), ranging from 18% to 71%, likely due to tissue excision in proximity of the external sphincter. Treatment of anastomotic stenosis after both prostatectomy and radiotherapy is understudied. We analyzed a multi-institutional series of radiated postprostatectomy men who underwent dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) for posterior anastomotic stenosis and hypothesize that D-BMGU is technically feasible in this population with durable patency while minimizing new SUI.

Figure. 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.

What We Found

In our cohort of 45 patients, 38 were patent at a median follow-up of 21 months (IQR 12-24), and there were no incidents of de novo SUI. Of the 7 recurrences only 2 occurred after 12 months. We found no evidence of differences in recurrence rate based on stricture location (P = .65) or timing of prostatectomy (P = .13). Postoperatively patients reported significant improvement in International Prostate Symptom Score, International Prostate Symptom Score quality-of-life domain, and postvoid dribble (P < .0001), and median postvoid residual and maximum urine flow rate significantly improved (P < .0001)

Limitations

This technique cannot be used for obliterative stenosis or anastomotic disruption. The retrospective nature of this study along with variations between institutions in preoperative and postoperative protocols potentially introduces selection bias.

Interpretation for Patient Care

D-BMGU is safe, feasible, and a durable reconstructive technique in patients with posterior urethral stenosis after both prostatectomy and radiotherapy. Zero patients experienced new SUI, and those with continued urinary incontinence were still able to undergo anti-incontinence procedures if desired.