Anastomotic fibrous ring as cause of stricture recurrence after Bulbar Onlay Graft Urethroplasty

Buccal mucosa graft onlay urethroplasty represents one of the most widespread methods for repairing strictures in the bulbar urethra.

Success rates have been high with dorsal or ventral grafts because of the bulbar urethra's thick and highly vascular spongiosal tissue. Stricture recurrence can develop despite adequate surgical technique however.

In a recent review by Guido Barbagli and colleagues from Italy, stricture recurrence after onlay urethroplasty with buccal mucosa grafts in the bulbar urethra is reviewed. The study in published in the August 2006 issue of the Journal of Urology.

Stricture recurrence after bulbar substitution urethroplasty using skin or buccal grafts has 2 features, namely extensive fibrous tissue involving the whole grafted area or a short fibrous ring stricture at the distal or proximal anastomotic sites. The authors investigated the prevalence, location and possible etiology of postoperative anastomotic ring strictures affecting 3 types of bulbar urethroplasty at the site where the graft was sutured to the apex of the urethral plate.

A total of 107 consecutive patients with an average age of 44 years underwent bulbar substitution urethral reconstruction between 1994 and 2004. Average stricture length was 4 cm, and a total of 102 patients underwent an average of 2.5 prior urethrotomies or dilations (range 1 to 11) before open repair. Forty-five patients had dorsally placed free skin grafts placed and 50 patients underwent a variety of buccal mucosa urethroplasties (17 ventral, 27 dorsal and 6 lateral). Average follow-up in the series was 74 months.

Analysis of the results showed that 85 cases (80%) were considered successes and 22 cases (20%) were considered failures. The 45 dorsal onlay skin graft urethroplasties provides successes in 33 cases (73%) and failure in 12 (27%). The 50 buccal grafts provided success in 42 cases (84%) and failure in 8 (16%).

In 12 group 1 cases (55%) the 22 failures involved the whole grafted area. These patients were eventually treated with perineal urethrotomies. In 10 group 2 cases (45%), the failures involved the anastomotic sites (5 distal and 5 proximal). These were the so-called "fibrous ring" strictures. The fibrous ring stricture thus had an occurrence of 9% in the entire group. The etiology of such strictures is unknown at this time. Possible etiologies of distal failure include a less robust urethral spongiosum as we go out distally and understaging may contribute to proximal anastomotic failures.

Written by Michael J. Metro, MD - UroToday

J Urol. 2006 Aug; 176(2):614-19