Two-sided Dorsal plus Ventral Oral Graft Bulbar Urethroplasty: Long-term Results and Predictive Factors
To evaluate long-term outcomes of the two-sided dorsal plus ventral oral graft (DVOG) urethroplasty by preserving the narrow urethral plate in tight bulbar strictures and investigated which factors might influence long-term outcomes.
Materials and Methods
We performed a retrospective study including 166 patients who underwent two-sided dorsal plus ventral oral graft (DVOG) urethroplasty between 2002 and 2013 for tight bulbar urethral strictures at our high-volume institution. Tight strictures were characterized by a very narrow residual urethral plate (width <3 mm). All surgical procedures were performed by the same urologist (E.P.). Inclusion criteria of the study were bulbar strictures treated with DVOG urethroplasty. Exclusion criteria were penile or panurethral strictures, obliterative traumatic strictures, lichen sclerosus, and failed hypospadias. The strictured urethra was opened ventrally; the exposed urethral plate was incised in the midline and augmented dorsally and ventrally using two oral grafts. Outcome was considered a failure when any postoperative instrumentation was needed. According to stricture length patients were classified in three groups: ≤1.5 cm (Group 1), >1.5 cm and ≤3.9 cm (Group 2) and ≥4 cm (Group 3). Time to failure was analyzed using Kaplan-Meier estimates and Cox regression.
Stricture length was ≤1.5 cm in 41 patients (24.7%; Group 1), >1.5 and ≤3.9 cm in 99 (59.6%; Group 2), and ≥4 cm in 26 (15.7%; Group 3). Mean±SD stricture length was 2.6±1.3 cm (range: 1-10).
A total of 127/166 patients (76.6%) have undergone previous treatments before referral to our center: internal urethrotomy in 64 (38.6%), urethroplasty in 2 (1.2%), dilatation in 3 (1.8%), multiple procedures in 58 (35%) patients. In patients previously treated with urethrotomy, the number of urethrotomies ranged from 1 to 20 (mean: 3).
Median follow-up was 47 mo (IQR: 33/95.5). Of the 166 patients, 149 (89.8%) were successful and 17 (10.2%) were failures. Median time to failure was 24 months (IQR: 12/36). Most of the failures (90%) were observed during the first 5 years of follow-up, afterward the success rate remained stable. The stricture length was a significant predictor of surgical outcome (odds ratio:1.743 per cm; CI: 1.2-2.5; p<0.001); patients with an urethral stricture >4 cm presented a higher risk of late failure. Age, stricture etiology, and previous treatment were not significant predictors of surgical outcome.
Surgical treatment of urethral stricture diseases is a continuous evolving process.
Short and/or sub-obliterative bulbar strictures are traditionally treated by excision and primary anastomotic urethroplasty, while longer strictures are usually repaired by patch graft urethroplasty preferably using oral mucosa. Anyway, the shortening of the urethra and the vascular injury following urethral transection may lead to an increased risk of sexual complications, explaining the new trend to use the patch grafting even in short strictures. However, the graft technique is mainly suggested in cases which require simple augmentation of the urethral plate without excision of the scarred urethra, while the question remains if this procedure is also suitable to treat tight bulbar urethral strictures including a particularly narrow area. The best approach to treat this kind of strictures, reducing at the same time the risk of complications related to traditional end-to-end anastomosis, is still an open problem with several proposed solutions. Guralnick et al. suggested the graft-augmented anastomotic repair with the aim of reducing the urethral chordee. The technique consists in the excision of the narrow portion and anastomosis on one-side of the urethra in conjunction with a patch graft on the opposite urethral side. A 90- 93% success rate was reported by using this procedure. Recently, Andrich described a new anastomotic repair of bulbar urethra strictures without transecting the urethra, whereas McAninch and Barbagli favoured the ventral grafting stating that excision of the narrow urethral plate was unnecessary because this grafting procedure provides a new sufficiently wide urethral plate.
Following the current trends of urethra-sparing surgery, we introduced the concept of a two-sided dorsal plus ventral grafting for very narrow strictures where a single graft would not be sufficient to obtain a lumen of adequate width and the transection may compromise the urethral vascularization and length. Our study shows that most of the failures (90%) were observed during the first 5 years postoperatively, afterward the success rate remained stable. This claims the need for strict follow-up especially in the first 5 years. Similarly to other studies, age, stenosis etiology and previous treatments (both urethrotomy or urethroplasty) were not significant predictors of surgical outcome.
Conversely, stricture length was identified as an independent risk factor for failure. The risk ofaving a re-intervention was increased by 70% for cm of urethral stricture length. Strictures > 4 cm (Group 3) presented a higher risk of failure when compared to strictures< 4 cm.
Bulbar urethral strictures are treated by various reconstructive techniques. Short or obliterative strictures may be treated with excision and anastomotic urethroplasty, while for longer strictures patch urethroplasty preferably using an oral graft has been advocated. However, since transecting procedures might impair sexual function probably as a consequence of the vascular damage and urethral shortening, new non-transecting and urethra-sparing techniques have been promoted for short stenoses
Our study demonstrates that in patients with tight bulbar strictures, the two-sided dorsal plus ventral oral graft urethroplasty provides high long-term success rates which may decrease primarily during the first 5 years; afterward the success rate remains stable.
The stricture length is an independent predictor of failure.
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