RECONSTRUCTIVE UROLOGY

The use of penile skin graft versus penile skin flap in the repair of long bulbo-penile urethral stricture: a prospective randomized study
Hussein MM, Moursy E, Gamal W, Zaki M, Rashed A, Abozaid A
Urology Department, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
Urology. 2011 Jan 3. [Epub ahead of print]

• Objectives: To evaluate the use of penile circular skin graft versus flap as a ventral onlay for bulbo-penile stricture urethra.
  Material and Methods: Between 2003 and 2009, 37 patients with bulbo-penile stricture were randomized to penile methods circular skin graft (PCG = 18) or flap (PCF = 19). Inclusion criteria included postinstrumentation or idiopathic stricture. Exclusion criteria were unhealthy skin and previous urethrotomy/urethroplasty. Patients had urethrogram at three weeks, three months, one year, and urethroscopy when needed. Any subsequent urethrotomy/urethroplasty was considered a failure. Chi-square and Student’s t test were used for analysis.
  Results: Patients’ ages were 45.3 (range: 30-65) and 45.5 (35-60) yr in PCG&PCF respectively. Stricture length was 15.2 (10-22) &14.1 (9-21) cm in PCG&PCF respectively. The stricture was postinstrumentation in 9 and 11 and idiopathic in 9 and 8 patients in PCG&PCF respectively. Mean follow up was 36.2 (12-60) and 37.1 (range: 13-24) months in PCG and PCF respectively. Operative time was significantly shorter in PCG than in PCF (203.3 and 281.6 min, respectively; P = .000). Early postoperative complications were similar in both groups. Superficial skin necrosis occurred only in the PCF group (3 cases). Late complications of mild postvoid dribbling occurred similarly in both groups. One patient in PCF had a urethro-cutaneaous fistula at the level of fossa navicularis that was repaired later. Stricture recurred in 5 (27.7%) and 4(21%) patients in PCG and PCF, respectively (P = .249). Four patients had visual internal urethrotomy (2, 2), four needed anastmotic urethroplasty (2, 2) in PCG and PCF, respectively, and one needed buccal mucosal graft in the PCG group.
  Conclusions: At intermediate follow-up, both penile circular graft and flap had similar and high success as a ventral onlay for repair of long bulbo-penile stricture with a low rate of complications.

• Editorial Comment
  Hussein et al. raise the bar in reconstructive urology research by completing a randomized clinical trial of distal penile fasciocutaneous skin flap urethroplasty vs. distal penile skin graft urethroplasty for non- lichen sclerosus strictures of the bulbo-penile urethra. They chose to compare two surgical techniques, which were similar in many ways but distinct in one important way. Similarities included the circumcising incision, the distal penile skin and the ventral onlay approach. The difference was in whether a graft or flap was used. The similarities in technique were likely helpful in recruiting patients. The similarities were also important in helping isolate the treatment effect of interest – flap vs. graft. Indeed, they did not detect a difference between the two groups in their primary outcome – a subsequent procedure to treat a stricture recurrence (21% for flap vs. 28% for graft). Here is where some additional planning could have strengthened the study. In order to detect a 10% difference at a significance level of p = 0.05 at a power of 0.8 they would have needed to randomize 353 patients to each arm of the study, rather than 19 patients as done here. Indeed, with only 19 patients in each arm they would have only been able to detect a massive difference between the recurrence rates. Additionally, the primary outcome of interest – need for additional procedures – introduces significant subjectivity into the success rates. A more objective outcome measure would have been preferable. Still, this study represents a great advance for the field of reconstructive urology and hope it will stimulate others to contribute randomized studies to the literature.

Dr. Sean P. Elliott
Department of Urology Surgery
University of Minnesota
Minneapolis, Minnesota, USA
E-mail: selliott@umn.edu