Bulbar urethroplasty using combined dorsal cum ventral onlay buccal mucosa graft: a novel technique.

Dear Editor, In urethral stricture disease, it is known that anastomostic urethroplasty with complete excision of scar tissue provide the best long-term outcome for short bulbar urethral strictures. Longer strictures are dealt with by onlay urethroplasties employing tissue substitution, using either flaps or grafts. In recent times, the buccal mucosa graft, whether laid dorsally or ventrally, has gained popularity.1,2 However, substitution urethroplasty often involves the incision of stricture only, leaving scar tissue behind. In an attempt to overcome this problem, Guralnick and Webster introduced the augmented anastomostic urethroplasty, where stricture of up to 2 cm is excised.3 However, this may not be possible in cases where the stricture is longer. Often, only the most diseased portion of the urethra is excised and the remaining portion of strictured tissue remains in-situ. In this regard, we report a novel technique combined ventral cum dorsal onlay buccal grafts with complete excision of diseased urethra to manage a bulbar urethral stricture greater than 2 cm. A 63-year-old Chinese male presents with a history of urethral stricture resulting from previous sexually transmitted disease. In addition to symptoms of poor urinary stream, dribbling and incomplete emptying for several years, he had recurrent scrotal and perineal abscesses that required repeated surgical drainage. Perineal examination revealed an urethro-cutaneous fistula opening in the perineum from which urine occasionally leaked. Retrograde urethrography showed a bulbar urethral stricture 2.5 cm in length, situated 0.5 cm distal to the external urethral sphincter (Fig. 1A). An inverted Y perineal incision was made and the bulbar urethra exposed and mobilised off the triangular ligament dorsally, the perineal body posteriorly and distally to the limit indicated by the suspensory ligament of penis. The urethra was transected at the distal margin of the stricture and dorsal stricturotomy made along the proximal end. The stricture had virtually occluded the urethral lumen leaving a thin strip of diseased native urethral tissue. The stricture was completely excised. However, the surrounding corpus spongiosus tissue, which was healthy, was left intact. The urethra was further incised 10 mm distally and 5 mm proximally until healthy urethral mucosa is seen; the proximal incision limited by the proximity of the external sphincter. Two strips of buccal mucosal were harvested from the inner left cheek. A 4.0 x 1.5 cm graft was spread-fixed dorsally onto the corporal bodies. A second graft, 2.5 x 1.5 cm, was laid and spread-fixed onto the healthy corpus spongiosum, in a ventral onlay manner. The 2 buccal grafts were then anastomosed together and then to the distal urethral stump. The repair was completed over a 12F siliconised catheter using interrupted absorbable sutures (polyglactin). Postoperative recovery was uncomplicated and postoperative urethrogram showed a patent bulbar urethra (Fig. 1B). The patient returned to normal micturition and enjoyed strong urinary stream at the last review at 20 months after surgery.