V12-01: Transurethral Ventral Buccal Mucosa Graft (BMG) Inlay Urethroplasty for Distal Urethral Strictures
Traditional options for distal urethral stricture repair involve penile skin incision to achieve access to urethra for various forms of external urethrotomy and subsequent repair with flaps or grafts. These incisions then require meticulous closure and are at risks of fistula formation, glans dehiscence and poor cosmetic outcomes. We introduce a novel surgical technique to repair fossa navicularis stricture without a need for skin incision. Our approach, a modified Naude technique, employs a ventral internal urethrotomy and precise transurethral delivery and fixation of BMG to the surface of the urethrotomy.
Surgical technique: a ventral urethrotomy is performed transurethrally and a shallow wedge of the obstructive tissue is removed to achieve access to a proximal patent lumen. Appropriate size BMG is then harvested and prepared for delivery. A double arm 6-0 polydioxanone suture is used: each arm of the suture is passed through the proximal apex of the graft then through the urethra at the proximal apex of the urethrotomy and externalized through the skin. By pulling on the arms of the suture externally the graft is delivered precisely into its place in the urethra. Additional 6-0 double armed sutures are used to quilt the graft at its mid portion and their knots tied externally. The distal edge of the graft is sutured to the edge of the meatotomy with absorbable sutures. A retrospective chart review was conducted of all the patients after a fossa navicularis/ distal urethral stricture repair since March 2014 by a single surgeon (DN). Surgical and functional outcomes including complications were reviewed. Uroflow and SHIM scores were evaluated pre- and post-operatively.
This surgery was performed for 7 patients including 3 circumcised males, 2 uncircumcised males with lichen sclerosus (LS) and 2 transgender patients with neophallus. Mean patient age was 39 years (25-55), mean stricture length 2.6 cm (1-4). At a mean follow up of 8.8 month (4-18), there were no stricture recurrences, fistula, penile chordee or adverse effects on sexual function. Mean uroflow pre-op was 5.5 (0-13), post-op 22 (16-37). SHIM score pre-op 19 (23-25), post-op 23 (22-25).
We demonstrated the feasibility of incisionless distal urethral/fossa navicularis stricture repair with ventral inlay BMG. This single stage technique allows avoiding skin incision or urethral mobilization. It prevents glans dehiscence or fistula formation. It avoids the use of genital skin flaps in patients affected with LS and is a viable option for patients with distal strictures in a neophallus.