RECONSTRUCTIVE UROLOGY

doi: 10.1590/S1677-55382010000400023

Antegrade endourethroplasty with free skin graft for recurrent vesicourethral anastomotic strictures after radical prostatectomy
Kuyumcuoglu U, Eryildirim B, Tarhan F, Faydaci G, Ozgül A, Erbay E
Dr. Lütfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey
J Endourol. 2010; 24: 63-7

• Purpose: To investigate the efficacy of the antegrade endourethroplasty technique for the management of frequently recurrent vesicourethral anastomotic strictures that develop after retropubic radical prostatectomy.
  Patients and Methods: Between January 2006 and February 2008, endoscopic antegrade urethroplasty was performed in 11 patients with recurrent vesicourethral anastomotic strictures that developed after retropubic radical prostatectomy (RRP). The mean age of the patients was 64.6 years. In the first step of this two-step procedure, the graft bed was prepared by transurethral resection of the vesicourethral anastomotic stricture region. In the next step, after 3 days, an Amplatz sheath was placed in the urinary bladder suprapubically. Then, an endobronchial catheter was inserted from the external urethral meatus and extended out of the body from the suprapubic region through the Amplatz sheath. A graft taken from anteromedial section of the arm was tubularized on the catheter balloon. The graft was placed into the bladder neck antegradely under endoscopic vision. Subsequently, the graft carrier catheter was fixed by previously placed two polypropylene sutures inserted into the proximal and distal part of the stricture zone percutaneously from the perineum. The transurethral catheter was taken out delicately on postoperative day 21.
  Results: Urethral patency succeeded in 6 of the 11 (54.5%) patients, and maximum flow rate was more than 13mL/s in follow-up. Graft necrosis occurred in two patients, and the stricture recurred in three patients in two months postoperatively.
  Conclusion: Antegrade endourethroplasty may be a suitable alternative to open surgical reconstruction in selected patients with recurrent bladder neck stricture following RRP. Further studies, including more patients with modifications, are needed to improve the success rate.

• Editorial Comment
  A minimally-invasive approach is appropriate in surgery when it offers results that are similar to those obtained with an open approach but with less morbidity. For this reason, the recalcitrant bladder neck contracture is the ideal stricture site for the development of the endoscopic urethroplasty. The alternatives are either unsuccessful (repeat dilation or urethrotomy) or are associated with high morbidity (urethral stent or open reconstruction). Still, concerns remain with this approach. First, a successful graft requires a healthy graft bed. Certainly, the recently resected and fulgurated TUR area is not an ideal graft bed. Second, results with tubular grafts or flaps in open urethral reconstruction have been poor. It is unclear why they should be any better with an endoscopic approach. Still, these initial results are encouraging and given the alternatives, a 55% success rate and flow rates of only 13-18cc/s are pretty good in these complex patients with few alternatives.

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