What is the next step after urethroplasty with oral mucosa graft for a 7cm penile urethral stricture?

Management After Urethroplasty with Oral Mucosa Graft for Penile Urethral Stricture

Augmentation urethroplasty with buccal graft is the recommended next step for this 70-year-old male with a 7cm penile urethral stricture following TURP who has already undergone urethroplasty with oral mucosa graft. 1

Rationale for Buccal Graft Augmentation

• For long penile urethral strictures (≥2cm), urethroplasty with oral mucosa grafts offers superior outcomes with success rates >80%, compared to only 20% success with endoscopic treatments 1
• Oral mucosa should be the first choice when using grafts for urethroplasty due to:
  • Higher patient satisfaction
  • Less post-void dribbling
  • Fewer penile skin problems 1, 2
• For this 7cm stricture, augmentation approach is preferred over tubularized repairs, as tubularized urethroplasty in a single stage has high risk of restenosis 1

Why Buccal Graft Over Other Options

Superiority over daily urethral self-dilation

• Daily urethral self-dilation is not appropriate for a 7cm penile urethral stricture as:
  • Endoscopic and dilation treatments have extremely poor success rates (only 20%) for strictures >4cm 1, 2
  • Penile urethral strictures are particularly resistant to endoscopic management 2

Advantages over penile skin flap

• Genital skin should be avoided, particularly if there's any suspicion of lichen sclerosus (common after TURP) 1
• Studies show stricture recurrence rates of 90% when genital skin was used as a graft, compared to no recurrence with buccal/bladder mucosa 1
• Buccal mucosa has demonstrated excellent results in multiple studies with success rates of 92% 3

Preference over two-stage urethroplasty

• One-stage procedures are preferred when possible to minimize patient morbidity 4
• Two-stage urethroplasty is typically reserved for:
  • Complex strictures with lichen sclerosus
  • Failed hypospadias repairs
  • Cases where the urethral plate is unusable 1, 4

When to consider perineal urethrostomy

• While perineal urethrostomy may be considered in this 70-year-old patient due to advanced age, it should be reserved for:
  • Patients with recurrent or primary complex anterior stricture
  • Medical co-morbidities precluding extended operative time
  • Extensive lichen sclerosus
  • Numerous failed attempts at urethroplasty
  • Patient preference 1

Surgical Technique for Buccal Graft Augmentation

• Dorsal onlay (Barbagli procedure) or ventral onlay techniques both show comparable success rates for bulbar urethral strictures 4
• For penile urethral strictures, options include:
  • Dorsal inlay with ventral sagittal urethrotomy (Asopa technique)
  • Dorsolateral onlay with one-sided urethral dissection (Kulkarni technique) 4, 5
• A two-team approach (one harvesting oral mucosa while another exposes the stricture) significantly reduces operative time 6

Postoperative Management

• Urethral catheter typically remains in place for approximately 3 weeks 7
• Regular follow-up should include:
  • Monitoring for recurrent lower urinary tract symptoms
  • Uroflowmetry and post-void residual measurements
  • Flexible cystoscopy in selected cases 2

Potential Complications to Monitor

• Distal anastomotic ring strictures (may require internal urethrotomy)
• Penoscrotal fistula formation
• Donor site complications (typically minimal) 7

In summary, augmentation urethroplasty with buccal graft represents the gold standard approach for this patient with a long penile urethral stricture following TURP, offering the highest success rates and quality of life outcomes.