Ventral oral mucosal onlay graft urethroplasty in nontraumatic bulbar urethral strictures: surgical technique and multivariable analysis of results in 214 patients

Abstract

Background: The ventral oral mucosal onlay graft is suggested in proximal bulbar strictures where the thick spongiosum provides excellent support to the graft. Some technical steps used in this technique are currently under debate in the literature.

Objective: To describe the surgical steps of this urethroplasty and investigate predictive factors of success using a multivariable logistic regression analysis.

Design, setting, and participants: This is a descriptive observational retrospective study of 214 patients who underwent urethroplasty for bulbar urethral strictures between May 1999 and November 2010 in a single high-volume center. Study inclusion criteria were patients presenting nontraumatic bulbar urethral strictures ranging from 1.3 cm to 6.8 cm in length. Exclusion criteria were traumatic strictures, panurethral strictures, lichen sclerosus, and failed hypospadias repair.

Surgical procedure: The oral graft was placed on the ventral bulbar urethral surface and pushed as proximally as possible using dedicated instruments and surgical techniques.

Outcome measurements and statistical analysis: The primary outcome measure was the objective result, defined as the absence of stricture recurrence at follow-up. The objective outcome was considered a failure when any postoperative instrumentation was needed. Multivariable logistic regression analysis was developed. All tests were two sided with a significance level set at 0.05.

Results and limitations: Median follow-up was 54 mo. Of the 214 patients, 183 (85.5%) were successful and 31 (14.5%) were failures. The preoperative maximum flow rate (Qmax) was a significant predictor of surgical outcome (odds ratio: 1.352; p = 0.001). Age, length, and type of stenosis, and previous treatment were not significant predictors of surgical outcome (all p > 0.05). The limitation of our survey is the absence of a subjective evaluation or the use of specific tools, such as a questionnaire.

Conclusions: Ventral oral graft urethroplasty represents a valid option in nontraumatic bulbar strictures. Preoperative Qmax may be predictive of urethroplasty failure.

Keywords: Bulbar urethra; Multivariable statistical analysis; One-stage urethroplasty; Oral mucosal graft; Urethral stricture.