Oral Mucosa vs. Penile Skin Flap in Substitution Urethroplasty for Anterior Urethral Strictures: A Systematic Review and Meta-Analysis

One-stage urethroplasty using a combination of buccal mucosa graft and Q penile skin flap for a complicated urethral stricture: A challenging case report

RATIONALE

Strictures of the male urethra are common, often caused by trauma or occur idiopathically. The primary clinical symptoms include chronic obstructive voiding issues, and some patients may experience sexual dysfunction. Treatment choices mainly depend on the stricture's location and length.

PATIENT CONCERNS

A 37-year-old man visited the urology department with lower urinary tract symptoms and recurrent urinary tract infections. He had a 5 cm urethral stricture previously treated with urethroplasty, which was unsuccessful.

DIAGNOSES

A retrograde urethrography revealed the stricture, an extra-anatomical bypass, and a diverticulum.

INTERVENTIONS

A second urethroplasty was performed, using a combination of a buccal mucosa graft and a penile skin flap.

OUTCOMES

Postoperative follow-up indicated improvement in the patient's voiding symptoms. A retrograde urethrography was done 3 months after the procedure showing a well-patent urethra with no complications.

LESSONS

The key factors in deciding the treatment for urethral strictures are their location and length. Both grafts and flaps are effective for urethroplasties. However, complex long strictures with damaged urethral plates pose challenges for successful single-stage reconstruction. Combining a dorsal buccal mucosa graft to augment the urethral plate with a ventral onlay penile skin flap is a promising approach, leveraging the benefits of both tissue types. Combining grafts and flaps is advisable for reconstructing complicated urethral strictures with damaged urethral plates. Consulting a more experienced surgeon is recommended to minimize the risk of complications.

Clinical questions in the Japanese Urological Association's 2024 clinical practice guidelines for urethral strictures

Transurethral procedures such as direct vision internal urethrotomy and urethral dilation have been the traditional treatments for urethral strictures. However, transurethral procedures are associated with high recurrence rates, resulting in many uncured cases and prompting major international urological societies to recommend urethroplasty as the standard treatment owing to its high success rate. In contrast, many Japanese general urologists have little doubts about treating urethral strictures with transurethral treatment. Therefore, urethral stricture treatments in Japan are not in line with those used in other countries. To address this, the Trauma, Emergency Medicine, and Reconstruction Subcommittee of the Japanese Urological Association has developed guidelines to offer standardized treatment protocols for urethral stricture, based on international evidence and tailored to Japan's medical landscape. These guidelines target patients with a clinically suspected urethral stricture and are intended for urologists and general practitioners involved in its diagnosis and treatment. Following the Minds Clinical Practice Guideline Development Manual 2020, the committee identified eight critical clinical issues and formulated eight clinical questions using the "patient, intervention, comparison, and outcome" format. A comprehensive literature search was conducted. For six clinical questions addressed by the existing guidelines or systematic reviews, the level of evidence was determined by qualitative systematic reviews. Quantitative systematic reviews and meta-analyses were performed for the two unique clinical questions. The recommendation grades were determined using the Delphi method and consensus by the committee. These guidelines will be useful to clinicians in daily practice, especially those involved in the care of urethral strictures.

The urinary and sexual outcomes of buccal mucosal graft urethroplasty versus end-to-end anastomosis: a systematic review with meta-analysis

Background

The urinary and sexual outcomes after urethroplasty may be a concern for patients, but there are still some controversies regarding the consequences of buccal mucosal graft urethroplasty (BMG) in terms of erectile dysfunction (ED).

Aim

This meta-analysis aimed to compare urinary and sexual outcomes of BMG and end-to-end urethroplasty (EE).

Methods

The PubMed, Web of Science, Cochrane, and Embase databases were searched until February 31, 2023. Data extraction and quality assessment were performed by 2 designated researchers. Dichotomous data were analyzed as odds ratios with 95% confidence intervals (CIs). Heterogeneity across studies was assessed by the I2 quantification, and publication bias using Begg's and Egger's tests. Meta-analysis was performed using RevMan software.

Outcomes

Outcomes included stricture recurrence, ED, penile complications, and voiding symptoms.

Results

Eighteen studies, including 1648 participants, were included in our meta-analysis. The meta-analysis revealed that there was no significant difference in stricture recurrence (OR = 0.74; 95% CI, 0.48-1.13; P = .17) and voiding symptoms (OR = 1.12; 95% CI, 0.32-3.88; P = .86) between the BMG group and the EE group. BMG was associated with lower risk of penile complications (OR = 0.40; 95% CI, 0.24-0.69; P = .001) and ED (OR = 0.53, 95% CI, 0.32-0.90, P = .02).

Clinical Implications

The study may help clinicians choose procedures that achieve better recovery of the urological and sexual function in the treatment of urethral stricture.

Strengths and Limitations

This meta-analysis is the first to evaluate the urinary and sexual outcomes of BMG vs EE. A limitation is that most of the included studies were retrospective cohort studies.

Conclusion

BMG is as effective as EE in the treatment of bulbar urethral stricture, but BMG has fewer complications and ED than EE.

Factors to Consider in Augmentation Urethroplasty with Oral Mucosa Graft or Penile Skin Flap for Anterior Urethral Stricture: A Systematic Review and Meta-analysis

Context

Oral mucosa graft (OMG) and penile skin flap (PSF) are common substitutions in urethroplasty; however, the recommended substitution for anterior urethral strictures remains uncertain.

Objective

To compare the efficacy of OMG and PSF in anterior urethral strictures in terms of success rate and prevalence of postvoid dribbling based on current studies.

Evidence acquisition

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and registered at PROSPERO (ID: CRD42022313879). All publications until March 1, 2022, were searched in the PubMed, EMBASE, and Cochrane Library databases without any restriction. Studies that focused on patients with anterior urethral strictures undergoing single-stage augmentation urethroplasty with OMG and PSF, and reported comparable success rates between the two substitutions were included.

Evidence synthesis

Thirteen studies involving a total of 1216 patients were included in the screening procedures, and 12 studies were eventually included in the meta-analysis. No significant difference in success rates was identified between OMG and PSF (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 0.96-2.07, p = 0.08). No significant difference was observed in the comparison of success rates in penile urethral strictures (OR: 0.95, 95% CI: 0.53-1.70, p = 0.86) and in the comparison of postvoid dribbling (OR: 0.59, 95% CI: 0.31-1.11, p = 0.10). However, a subgroup analysis suggested that OMG had a higher success rate than PSF in studies with the top 50% sample size (six studies, OR: 1.678, 95% CI: 1.055-2.668, p = 0.029) and the top 50% follow-up period (five studies, OR: 2.279, 95% CI: 1.193-4.352, p = 0.013).

Conclusions

OMG provides the same success rate and postvoid dribbling as PSF. However, based on the existing evidence, OMG is more likely to perform better in a cohort with long-term follow-up and a relatively large sample size. More studies on the two substitutions are necessary to evaluate the factors of urethroplasty success rate, performance of substitutions in penile urethral strictures, and indicators of quality of life.

Patient summary

In this research, we compared the outcomes of oral mucosa graft (OMG) and penile skin flap for urethroplasty in anterior urethral stricture patients in 13 studies. We found that these were similar in terms of success rate and postvoid dribbling. However, OMG could probably provide a higher success rate when the studies had more patients or a longer follow-up period.

A TriNetX Registry Analysis of the Need for Second Procedures following Index Anterior and Posterior Urethroplasty

BACKGROUND

We queried a global database to understand re-intervention rates following urethroplasty with the goal of evaluating whether they align with previously published data.

METHODS

Using the TriNetX database and Common Procedural Terminology (CPT) and International Classification of Diseases-10 (ICD) codes, we identified adult male patients with urethral stricture disease (ICD N35) who underwent one-stage anterior (CPT 53410) or posterior urethroplasty (CPT 53415), with or without (substitution urethroplasty) a tissue flap (CPT 15740) or buccal graft (CPT 15240 or 15241). We set urethroplasty as the index event and used descriptive statistics to report the incidence of secondary procedures (using CPT codes) within 10 years after the index event.

RESULTS

There were 6606 patients who underwent urethroplasty within the last 20 years, with 14.3% of patients undergoing a second procedure after index event. Upon subgroup analysis, reintervention rates were 14.5% for anterior urethroplasty vs. 12.4% of patients with an anterior substitution urethroplasty (RR 1.7, p = 0.09) and 13.3% for posterior urethroplasty vs. 8.2% for patients with a posterior substitution urethroplasty (RR 1.6, p < 0.01).

CONCLUSIONS

Most patients will not need any form of re-intervention following urethroplasty. These data align with previously described recurrence rates, which may help urologists counsel patients considering urethroplasty.

Dorsal oral mucosa graft urethroplasty for female urethral stricture reconstruction: A narrative review

Female urethral stricture is currently a challenging situation. In general, urethra dilatation can be selected for treatment, but the complications and high recurrence rate urge doctors to consider other treatments. Recently, dorsal oral mucosa graft urethroplasty is concerned by more and more surgeons, but there are not enough reports so far. A comprehensive search of dorsal oral mucosa graft urethroplasty was performed. According to the existing literature, there are applications of buccal mucosa and lingual mucosa, and compared with other kinds of grafts, the success rate is higher. However, there is a lack of multicenter, large sample and long follow-up studies. And there is still no enough comparative study between different types of oral mucosa. In summary, dorsal oral mucosa graft urethroplasty is an effective option for the management of female urethral stricture. More multicenter and large sample studies with long-term follow-up data are needed.

Smoking is an independent risk factor for stricture recurrence after the urethroplasty: a systematic review and meta-analysis

OBJECTIVE

To clarify the association between smoking and stricture recurrence after urethroplasty.

MATERIALS AND METHODS

Pubmed, Web of Science, Embase, and Cochrane databases were searched with keywords: "urethroplasty," "buccal mucosa graft urethroplasty," "oral mucosa graft urethroplasty," "excision and primary anastomosis urethroplasty," "urethral stricture recurrence" until July 1, 2022. Inclusion and exclusion criteria were based on PICOS principles. The quality of included studies was assessed by Newcastle-Ottawa Scale (N.O.S.) system. Hazard ratio (H.R.), odds ratio (OR), and relative risk (RR) with 95% confidence interval (CI) were extracted or re-calculated from included studies. Meta-analysis was performed with Stata 15.0 based on univariate and multivariate data separately. Sensitivity analysis was performed to test the stability of the meta-analysis. I2 was calculated to evaluate heterogeneity. Publication biases were assessed by Egger's and Begg's tests. Funnel plots of univariate analysis and multivariate analysis were also offered.

RESULTS

Twenty one studies with 6791 patients were involved in this meta-analysis. The analysis results of the two stages were consistent. In the univariate meta-analysis stage, 18 studies with 5811 patients were pooled, and the result indicated that smoking might promote stricture recurrence (RR=1.32, P=0.001). Based on the adjusted estimate, 11 studies with 3176 patients were pooled in the multivariate meta-analysis stage, and the result indicated that smoking might promote stricture recurrence (RR=1.35, P=0.049). There was no significant heterogeneity in both the univariate and multivariate stages.

CONCLUSION

Our study demonstrates that smoking may prompt stricture recurrence after the urethroplasty. Quitting smoking may be a good option for patients undergoing urethroplasty surgery.