Panurethral and long strictures

Santucci 10/2014

http://academy.siu-urology.org/siu/2014/glasgow/59224/richard.santucci.urethroplasty.for.long.segments.and.panurethral.strictures.a.html

Introduction
The management of long segment and panurethral strictures is sparsely described in the literature yet these are the most difficult to treat urethral strictures. Further, there is no consensus on the best surgical treatment of long and panurethral strictures. This study presents the results of an international multi-institutional collaborative review of the largest available series of long segment and panurethral stricture repairs. The authors seek to better understand the management of long segment and panurethral strictures, and the complications and success rates of various treatment options by examining results of common procedures and features predictive of surgical success.
Materials and Methods
A retrospective review was performed of patients treated with strictures longer than 8 cm at 7 different international tertiary referral centers. Data collected included demographics, cause of stricture, prior dilation or DVIU, prior urethroplasty, length of stricture, and surgical approach. Endpoints analyzed included surgical complications and recurrence.
Results
466 patients were identified. Treatment intervals ranged from 12/27/1984 to 11/9/2013 and included the experience of 7 experts in the field. Dorsal onlay buccal mucosa graft was the most common procedure utilized (223, 47.9%) while other techniques included first stage Johanson (including perineal urethrostomy) (162, 34.8%), second stage Johanson (56, 12%), fasciocutaneous flaps (8, 1.7%) and a combination flap and graft (17, 3.6%). Overall success was achieved in 361 patients (77.5%) with a mean follow up of 20 months. Recurrences of the various surgical types were similar; however, second stage Johanson urethroplasty was found to have a higher recurrence rate compared to one-stage buccal mucosal graft urethroplasty (35.7% versus 17.5%, respectively, p <0.01). In cases of lichen sclerosis, the recurrence rate was higher after second stage Johanson versus after a one-stage buccal graft procedure (14.0% versus 47.8% respectively, p <0.01). Those urethroplasties performed with a fasciocutaneous flap had a higher complication rate compared to those performed without (32% versus 14%, respectively, p =0.02). Prior dilation or urethrotomy, higher number of prior dilations or urethrotomies, abnormal postoperative voiding cystourethrogram, and skin grafts all portend a higher recurrence rate. Stricture length and location of buccal mucosal graft appear to have no impact on recurrence. On logistic regression analysis, only second stage Johanson had an increased odds ratio of recurrence compared to BMG, at 2.82 (1.41-5.86).
Conclusions
Panurethral and long segment strictures can be treated with high success rates in experienced hands. Considering all techniques, a 77.5% success rate was noted. Buccal grafts were particularly more successful than second stage Johanson urethroplasty (82.5% versus 64.3%, respectively). Fasciocutaneous flaps, while successful, had high complication rates.

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