Urology Video Journal (Mar 2022)
Bulbomembranous urethral strictures after transurethral resection of the prostate. Ventral oral mucosal graft non-transecting urethroplasty technique
Abstract
Background: Transurethral resection of the prostate (TURP) is one of the main causes of iatrogenic urethral stricture (1). Post-TURP bulbar strictures are often very close to or include the membranous urethra. Surgical management is challenging due to the risk of incontinence, erectile dysfunction, and the limited success of endoscopic approaches. Despite being a frequent clinical scenario, there is a lack of studies that specifically analyze surgical correction in this particular subset of post-TURP strictures (2). Objective: To describe our step-by-step technique for the ventral approach of post-TURP bulbomembranous strictures. Material: Rationale of this technique lies in the anatomical disposition of the external urethral sphincter which is an omega-shaped structure deficient posteriorly (3). Regarding the membranous urethra, this is an intraurethral technique and all the structures that surround the corpus spongiosum laterally and dorsally are preserved (4). Therefore, the risk of sphincter damage is minimal.To analyze our results with this technique, we reviewed our continuous prospective database of all urethral interventions performed in our center since 2015. We selected the cases corresponding to post-TURP strictures with bulbomembranous involvement treated with this technique and with at least 1 year follow-up. Furthermore, a telephone interview was conducted to update the patients' clinical status. Results: Ten patients were analyzed. Mean age: 63 years (43–72). Mean stricture length in voiding cystourethrogram was 1.8 cm (1-3). In all of them, bulbomembranous involvement was reported and also all had at least one previous unsuccessful urethrotomy. After median follow-up of 26 months (12–56), 100% of the patients remained recurrence-free. Median Qmax and Qmed significantly improved at 1 year follow-up from 5.9 to 3.5 ml/seg to 17 and 9 ml/seg, respectively. The PROM-USS median score (questions 1–6) improved from 15 points before to 4 points 1 year after surgery. Seven out of ten patients were very satisfied and three out of ten were satisfied at 1 year follow-up. Median quality of life assessment score improved from 50/100 before to 80/100 1 year after surgery. All patients were specifically interviewed about their continence status and none of them suffered any form of postoperative incontinence. Conclusions: There are no comparative studies that can answer the question of which is the best technique in this subgroup of patients. In the absence of evidence, we believe that the ventral approach is suitable for post-TURP strictures close to or involving the membranous urethra, providing a long-term solution for these patients. The risk of incontinence through this approach is minimal.
