In patients with a history of radiation therapy, urethral strictures are reported the most common late, grade 2-3 urinary toxicity occurring within a range of 2-8 years following treatment.(1-3) Various techniques have been described for the surgical management of urethral strictures.(4) However, stricture repair in previously irradiated tissue may be more challenging due to periurethral fibrosis and compromised vascular supply induced by radiation.
Consequently, patients are at a high risk for adverse postoperative outcomes, namely urinary incontinence, erectile dysfunction and stricture recurrence.(5) Within this context evidence suggests success rates of 69.7 to 90.0% for open urethral reconstruction in these patients. However previous reports mainly focused on outcomes of anastomotic urethroplasties such as excision and end-anastomosis.(6-8) Though, strictures in previously irradiated patients are reported to be of median 2.3-2.9cm length,(6-8) and may therefore warrant graft or flap substitution urethroplasty.(1)
As most European centres we perform buccal mucosa graft urethroplasty (BMGU) as the standard treatment for urethral strictures longer than 1 to 2cm.(9-11) Therefore the aim of our study was to specifically report on outcomes of ventral BMGU in patients with urethral stricture disease following radiotherapy. Endpoints of our study focused on stricture-free survival, functional outcomes as well as patients’ satisfaction following surgery.
38 patients, who underwent ventral onlay BMGU between January 2009 and October 2013 were included in the study. Prostate cancer was the most common indication for radiation therapy. Strictures were located in the bulbar/bulbomembranous urethra and had a mean length of 2.9cm (median: 3.0, range: 1.0-8.0). Following BMGU, overall success rate was 71.1% after a mean follow-up of 23.7 months (median: 26.5, range: 1.0-50.0). However, we observed a steady increase of risk for stricture recurrence over time: while stricture-free survival one year following BMGU was 90%, success rates at the 3- and 4-year follow-up were respectively 76.0 and 39.0%. Mean time to stricture recurrence was 19.3 months (median: 17.0, range: 3.0-44.0). Neither prior treatment, nor modality of radiation therapy or stricture length was a statistically significant risk factor for stricture recurrence. De-novo urinary incontinence was observed in 10.5% of the patients. Overall, 24.3% of our cohort received an artificial urinary sphincter following BMGU. Erectile function remained unchanged compared to preoperative status in the majority of patients (93.8%). 55.9 and 35.3% of the patients were very satisfied or satisfied with their outcome after surgery. 8.8% reported being “unsatisfied”.
In conclusion, we provide the first report on urethral reconstruction in previously irradiated patient purely undergoing ventral onlay BMGU, demonstrating an acceptable success rate in the short- to mid-term follow-up. However, patients need to be counselled about the increased risk of urinary incontinence, and furthermore about stricture recurrence. Considering a median age of 70 years of our cohort, pros and cons of urethral reconstruction need to be thoroughly weighted against each other whereupon selected patients might profit more from maintenance with a suprapubic catheter or a Mitrofanoff appendico-vesicostomy for (12). Finally, longer follow-up is warranted to address long-term outcomes. Further limitations of our study include the small sample size and lacking use of validated questionnaires.
Written by: Priv.-Doz. Dr. med. Sascha A. Ahyai, Sascha A. Ahyai, MD, FEBU
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