Reconstruction of Failed Urethroplasty

Summary

While initial open urethroplasty has a success rate of approximately 90 %, salvage repairs do not fare as well, having a success rate of roughly 80% on average. Failed anastomotic repairs are usually the result of an inadequate excision of fibrotic tissue and/or inadequate distal urethral mobilization, resulting in an anastomosis performed under tension. The mainstay of treatment for recurrent penile urethral strictures remains a flap procedure with penile shaft skin. It is crucial to resect redundant sacculations, residual scar, or hair-bearing tissue remaining from prior procedures at the time of reconstruction. If distal stenosis should occur after a flap procedure, extended meatotomy is highly effective. Strictures most amenable to excision with re-anastomosis are those in the proximal bulb—these allow for maximal use of the elastic properties of the distal bulbar urethra to bridge the gap created once the scarred segment is excised. For strictures greater than 3 cm. in length located in the distal bulb, patch graft (penile skin or buccal mucosa) is the most effective and efficient approach. The primary reason for failure of a primary open urethroplasty of the posterior urethra is inadequate exposure of the prostatic apex, resulting in incomplete excision of scar tissue. Urethral stenosis may recur after any of the above types of open urethral reconstruction — fortunately the recurrent stricture is often short and web-like, and usually responds well to a single urethral balloon dilation or direct visual internal urethrotomy, because it is associated with less underlying spongiofibrosis.