Ventral Buccal Mucosa Graft Urethroplasty with Gracilis Muscle Flap for High Risk, Long Segment Urethral Strictures: A 20-Year Experience

Objective: To evaluate our 20-year experience of urethroplasty with ventral buccal mucosa graft (BMG) and gracilis muscle flap coverage for long segment urethral strictures unfit for standard repair due to a compromised graft bed and poor vascular supply. Methods: We retrospectively reviewed the records of 1687 patients who underwent urethroplasty at our institution between 1999 and 2019. We identified 30 patients who underwent urethroplasty with a ventral BMG and gracilis muscle flap graft bed. Stricture recurrence was defined as the inability to pass a 17-French cystoscope. Results: Mean stricture length was 7.6 centimeters (range 3.5-15). Strictures were located in the posterior urethra with or without involvement of the bulbar urethra in 60% of cases, the bulbomembranous urethra in 30%, the bulbar urethra in 6.7%, and the proximal pendulous urethra in 3.3%. Stricture etiology was radiation therapy in 60% of cases, prostatectomy in 23.3%, transurethral surgery in 13.3%, idiopathic in 13.3%, trauma in 10%, and hypospadias failure in 3.3%. Ten (33.3%) patients were previously treated with urethroplasty, 26 (86.7%) had prior endoscopic stricture management, and 3 (10%) previously underwent UroLume stent placement. Urethral reconstruction was successful in 23 cases (76.7%) at a mean follow-up of 32 months (range 4-92). Two of the patients in whom treatment failed underwent urinary diversion, 3 underwent suprapubic tube placement, 1 had endoscopic urethral dilation, and 1 had direct visual internal urethrotomy performed. Mean time to recurrence was 8 months (range 2-17). Postoperatively, 7 patients (23.3%) had incontinence requiring artificial urinary sphincter placement. Conclusion: Ventral BMG urethroplasty with gracilis muscle flap coverage can be successfully performed for high risk, long segment urethral strictures, avoiding urinary diversion in most patients.