Long-segment and panurethral strictures have been a challenge for reconstructive urologists. Defining “panurethral” has been a matter of debate and used in a wide range in different studies. In a recent study long-segment or panurethral stricture was defined as any single stricture or multifocal diseased areas of the penile and bulbar urethra measuring ≥ 8 cm in length. The etiology of panurethral strictures may vary in industrialized and developing countries. Urethral strictures mostly have iatrogenic or idiopathic origin in industrialized countries and the most common cause of panurethral stricture is genital lichen sclerosus in developing countries.There have been many surgical techniques used for the treatment of panurethral strictures. More recently, single-stage procedures using grafts and flaps were popularized with comparable success rates. Kulkarni et al. developed a dorsal onlay augmentation urethroplasty technique for the treatment of panurethral strictures. Using a perineal approach and penile invagination, exposure was excellent and one sided urethral dissection allowed the preservation of the neurovascular supply of the contralateral side. The aim of this study is to present the results of our double buccal mucosal urethroplasty series for panurethral strictures.

We included the first 35 patients who had one stage double buccal mucosal graft urethroplasty with one side dissection of the urethra which was described by Kulkarni, between January 2015 and June 2018 and had at least 6 months follow-up. From the first case, all data were recorded prospectively and patient age, etiology of the stricture, comorbidities, previous treatments, postoperative maximal flow rate, pre and post-operative erectile function, perioperative and postoperative complications and quality of life questionnaire for this study.

The patients data, characteristics, preoperative and postoperative findings was shown at the table.

The preoperative data and the postoperative results of the patients are given in Table starting from the first to the last patient who had at least 6 months of follow-up. The mean patient age was 58.8 (between 27 and 82) and the mean stricture length was 13.7 cm (from 10 to 16 cm). Patients had previously 1 to 17 (mean 3.5 and median 3) procedures. Patients had a mean peak flow rate (Qmax) of 5.2 ml/sec (between 0 and 12.3 ml/sec) preoperatively which significantly increased to 25.4 ml/sec (between 12.1 and 40.0 ml/sec) at the first postoperative visit (P<0.001).

During the follow-up period, 6 patients had recurrent urethral strictures. Recurrence-free survival was shown in Figure-6. Three patients with a recurrence on the proximal anastomosis site were managed with direct vision internal urethrotomy and urethral dilation, 2 patients needed re-urethroplasty with buccal graft and one patient with a meatal stenosis and recurrence at the intersection of two buccal mucosal grafts was managed with urethral dilation and meatoplasty. During the follow-up, 3 (8.6%) patients had penile curvature, 4 (11.4%) patients had deterioration in erectile function when compared to the preoperative status, as stated by the patients, 2 (5.7%) patients had stress urinary incontinence and 2 (5.7%) patients had oral complications (one had numbness and the other had contracture).

We also investigated the factors that would contribute to the success rate. When patients were grouped according to age, there were 14 patients older than 65 years of age (Group 1) and 21 patients who were 65 years old or younger (Group 2). There were 5 patients (35.7%) who had recurrence in group 1 whereas only 1 patient (4.8%) had recurrence in group 2 (P=0.028). Therefore age, particularly older than 65 years was a significant risk factor for recurrence. We could not demonstrate a significant association between recurrence and comorbidities, etiology of the stricture, the number of previous interventions and stricture length.

The responses to the questions about satisfaction from the surgery showed that 31 (88.6%) patients were satisfied with the surgery, 33 (94.3%) would prefer this procedure again, if needed, and 31 (88.6%) patients recommended this procedure to others. Regarding buccal mucosa harvesting, 27 (77.1%) patients were contented about buccal mucosa harvesting, 25 (71.4%) were positive about consenting again for buccal mucosa harvesting, and 22 (62.9%) accepted urethroplasty with buccal mucosa again although they had been offered another alternative.

In this study, we demonstrated that Kulkarni’s one-stage double buccal mucosa urethroplasty technique has a high success rate in patients with panurethral strictures. The patient satisfaction is high because of the good functional outcomes and low complication rate. Our study showed that, after a proper training this technique can be transferred to any center and easily applicable. Patient age, particularly older than 65 years is a significant risk factor for recurrence after urethroplasty in patients with panurethral strictures. Although the success rate is high, there is a lack of information in the literature about the factors affecting success rate. Further studies with higher number of patients are needed to clarify this issue.

Kulkarni S, Barbagli G, Sansalone S, et al. One-sided anterior urethroplasty: a new dorsal onlay graft technique. BJU Int 2009;104:1150-5.
Warner JN, Malkawi I, Dhradkeh M, et al. A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures. Urology 2015;85:1483-7.
Kulkarni S, Barbagli G, Kirpekar D, et al. Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol 2009;55:945-54.