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Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis
2024; Lippincott Williams & Wilkins; Volume: 211; Issue: 4 Linguagem: Inglês
10.1097/ju.0000000000003848
ISSN1527-3792
AutoresJoshua Sterling, Jay Simhan, Brian J. Flynn, Paul Rusilko, Wagner A. França, Erick A. Ramírez, J.C. Angulo, Francisco E. Martins, Hiren V. Patel, Margaret Higgins, Daniel Swerdloff, Dmitriy Nikolavsky,
Tópico(s)Genital Health and Disease
ResumoOpen AccessJournal of UrologyAdult Urology26 Jan 2024Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis Joshua Sterling, Jay Simhan, Brian J. Flynn, Paul Rusilko, W. A. Franca, Erick A. Ramirez, Javier C. Angulo, Francisco E. Martins, Hiren V. Patel, Margaret Higgins, Daniel Swerdloff, and Dmitriy Nikolavsky Joshua SterlingJoshua Sterling https://orcid.org/0000-0002-7097-6485 Department of Urology, Yale School of Medicine, New Haven, Connecticut Department of Urology, SUNY Upstate Medical University, Syracuse, New York , Jay SimhanJay Simhan https://orcid.org/0000-0003-2262-7376 Department of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania , Brian J. FlynnBrian J. Flynn https://orcid.org/0000-0001-7915-2186 Division of Urology, University of Colorado School of Medicine, Aurora, Colorado , Paul RusilkoPaul Rusilko https://orcid.org/0000-0002-5402-6623 Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania , W. A. FrancaW. A. Franca Department of Urology, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil , Erick A. RamirezErick A. Ramirez Hospital Angeles Mocel, Mexico City, Mexico , Javier C. AnguloJavier C. Angulo Department of Medical Clinic, Universidad Europea de Madrid, Madrid, Spain , Francisco E. MartinsFrancisco E. Martins University of Lisbon, Hospital Santa Maria, Lisbon, Portugal , Hiren V. PatelHiren V. Patel Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey , Margaret HigginsMargaret Higgins Division of Urology, University of Colorado School of Medicine, Aurora, Colorado , Daniel SwerdloffDaniel Swerdloff https://orcid.org/0000-0001-6302-3400 Department of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania , and Dmitriy NikolavskyDmitriy Nikolavsky *Corresponding Author: Dmitriy Nikolavsky, MD, Department of Urology, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210 E-mail Address: [email protected] https://orcid.org/0000-0002-8716-8740 Department of Urology, SUNY Upstate Medical University, Syracuse, New York View All Author Informationhttps://doi.org/10.1097/JU.0000000000003848AboutAbstractPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinked InEmail Abstract Purpose: The treatment of urethral stenosis after a combination of prostatectomy and radiation therapy for prostate cancer is understudied. We evaluate the clinical and patient-related outcomes after dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) in men who underwent prostatectomy and radiation therapy. Materials and Methods: A multi-institutional, retrospective review of men with vesicourethral anastomotic stenosis or bulbomembranous urethral stricture disease after radical prostatectomy and radiation therapy from 8 institutions between 2013 to 2021 was performed. The primary outcomes were stenosis recurrence and development of de novo stress urinary incontinence. Secondary outcomes were surgical complications, changes in voiding, and patient-reported satisfaction. Results: Forty-five men were treated with D-BMGU for stenosis following prostatectomy and radiation. There was a total of 7 recurrences. Median follow-up in patients without recurrence was 21 months (IQR 12-24). There were no incidents of de novo incontinence, 28 patients were incontinent pre- and postoperatively, and of the 6 patients managed with suprapubic catheter preoperatively, 4 were continent after repair. Following repair, men had significant improvement in postvoid residual, uroflow, International Prostate Symptom Score, and International Prostate Symptom Score quality-of-life domain. Overall satisfaction was +2 or better in 86.6% of men on the Global Response Assessment. Conclusions: D-BMGU is a safe, feasible, and effective technique in patients with urethral stenosis after a combination of prostatectomy and radiation therapy. Although our findings suggest this technique may result in lower rates of de novo urinary incontinence compared to conventional urethral transection and excision techniques, head-to-head comparisons are needed. Radiation therapy and surgical resection remain the primary treatment modalities for intermediate- and high-risk localized prostate cancer patients. Urologic complications, including vesicourethral anastomotic stenosis (VUAS) or bulbomembranous urethral stenosis, are known sequela of these treatments with a wide range of incidence rates depending on surgical approach and type of radiation.1,2 These rates are even greater, nearing 50% in some series, in patients who need both radiotherapy and extirpative surgery.3-6 Posttreatment urethral stricture or VUAS poses long-lasting morbidity for patients following prostate cancer treatment, leading to burdensome hospital visits/procedures, increased expenditures, and terrible quality of life (QOL). Surgical management of posterior urethral stenosis after prostatectomy and radiotherapy poses multiple technical and functional challenges. Endoscopic attempts to manage stenosis are universally ineffective and excisional urethroplasty techniques for the repair of postradiation urethral stenosis have been shown to have substantial rates of de novo stress urinary incontinence (SUI), ranging from 18% to 71%, likely due to the proximity of the external sphincter.6-13 Further, prior investigators have contended that strategies to minimize postoperative morbidity such as incontinence with utilization of buccal mucosa graft (BMG) substitution might be doomed to fail given the need for the graft to "take" in a radiated bed.3,14 We analyze a multi-institutional series of radiated postprostatectomy cancer survivors who underwent dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) for posterior urethral stenosis and hypothesize that D-BMUG is technically feasible in this population with durable patency while minimizing de novo SUI. Materials and Methods Patient Selection A multi-institutional retrospective analysis was done with Institutional Review Board approval (IRB No. 1596265-1). Prostate cancer patients treated with radical prostatectomy and radiotherapy who underwent surgical treatment for posterior urethral stenosis at participating institutions between 2013 and 2021 were included. Following preferred Société Internationale d'Urologie/International Consultation on Urologic Diseases terminology, we reviewed cases with "nonobliterative, posterior urethral stenosis," to include patients who had stenosis in the posterior urethra anywhere from the distal bladder neck to the proximal bulbar urethra, that met our initial inclusion criteria.15 Primary outcomes were stenosis recurrence and incidence of de novo SUI. Secondary outcomes included qualitative and quantitative assessment of changes in voiding function (maximum urine flow rate [Qmax], postvoid residual ([PVR]), International Prostate Symptom Score [IPSS], spraying urinary stream, and postvoid dribbling, sexual function (Sexual Health Inventory for Men [SHIM] score), and overall patient satisfaction using the Global Response Assessment (GRA). Patient demographics, medical history, cancer and stenosis treatment courses, presence of preoperative suprapubic catheter (SPC), stricture location, and length were reviewed (Table 1). Operative reports were reviewed to identify stricture length, operative time, complications, estimated blood loss, and transfusions. Perioperative outcomes: stenosis recurrence, preoperative and postoperative Qmax and PVR, and validated patient-reported outcome measures (PROMs) such as GRA, IPSS, and SHIM questionnaires were assessed as described below. Table 1. Patient Characteristics n = 45 Age, median (IQR), y 68 (62.5-72) Health characteristics BMI, median (IQR) 29.4 (25.6-31.5) HTN, No. (%) 31 (72) Diabetes, No. (%) 21 (49) Tobacco use, No. (%) 14 (32) Race, No. (%) White non-Hispanic 29 (64) Hispanic 7 (16) Black non-Hispanic 5 (11) Asian 1 (2.3) Unknown 3 (6.7) Type of prostatectomy, No. (%) Primary 40 (89) Salvage 5 (11) Prior interventions, No. (%) Dilations 32 (84) DVIU 26 (68) TURP/TUIP 10 (26) Time from radiation to symptoms, median (IQR), mo 48 (28.5-88.5) Radiation dose, median (IQR), Gya 73 (69-76) Preoperative SPC, No. (%) 37 (86) Stenosis location, No. (%) Anastomotic 21 (47) Bulbomembranous 24 (53) Stenosis length, median (IQR), cm 2.3 (2-3.6) Follow-up of patients without recurrence, median (IQR), mo 21 (12-24) Abbreviations: DVIU, xxx; HTN, xxx; SPC, suprapubic catheter; TUIP, xxx; TURP, xxx. Radiation dose was known for 26 of 45 patients Surgical Technique D-BMGU starts with cystoscopy and passage of a guidewire across the stenosis into the bladder. Urethral dissection starts dorsolaterally on one side and continues dorsally between the 11- to 1-o'clock position; preserving urethral continuity by avoiding ventral dissection and transection of the bulbar vessels as described by Kulkarni et al.16 After meticulous dorsal dissection and lateral rotation sparing the striated muscle of the rhabdosphincter and avoiding cavernous nerves located ventrolaterally, the space between the diverging crura is exposed.17,18 The dorsal aspect of the urethra is incised longitudinally through the length of stenosis, with assistance of the preplaced guidewire or sound, extending approximately 1.5 cm proximal and distal into healthy urethra and bladder neck (Figure 1). Cautery is not used near the membranous urethra and cavernous nerve mesh. A shallow wedge of dorsal periurethral scar tissue is sharply excised. This resection is limited to the area between the 11- and 1-o'clock positions facilitating preservation of the omega-shaped rhabdosphincter.18 Three absorbable stitches are passed outside-in, through the apex end of the urethrotomy, at the 11-, 12-, and 1-o'clock positions. A nasal speculum or urethral gorget can assist in the placement of these proximal stitches (Figure 1). An appropriately sized BMG is harvested and secured proximally with the preplaced apical sutures. Absorbable sutures are used to quilt the BMG dorsally to the periurethral area proximally and corpora cavernosa distally, and to complete the urethra-graft anastomoses. Figure 1. A, Lateral dissection of urethra and dorsal urethrotomy. Dotted line indicates area to be excised. B, Intercrural tissue is excised anterior between 1- and 11-o'clock positions. C, Buccal mucosa is sutured to proximal apex of urethrotomy and quilted on corpora cavernosa. D, Intraoperative image after dorsolateral dissection and excision of stenotic region. Urethral mucosa is stained with methylene blue. A nasal speculum is placed in the urethra to aid in placement of apical stitches. Arrows show double-arm sutures placed apically ready for parachuting of the graft. E, Intraoperative image, after buccal mucosa graft is quilted dorsally and the medial graft-urethra running anastomosis has been completed. Urethral gorget is placed in the urethra to aid in visualization during quilting and anastomosis. F, Postoperative voiding cystourethrography at time of catheter removal. G, Preoperative voiding cystourethrography and retrograde urethrography in patient with recurrent stenosis following RALP and adjuvant EBRT. Urethra is still patent at last follow-up, 96 months. Follow-Up Patients were seen at 3 weeks for voiding cystourethrography/retrograde urethrography and catheter removal. If there was concern for extravasation of contrast the catheter was left for another week. Patients were followed at 3- to 6-month intervals postoperatively for the first 12 months and yearly thereafter to assess recurrence. Stenosis recurrence was defined as need for any intervention, including endoscopic treatments or revision urethroplasty during follow-up. In all institutions, patients were followed with uroflowmetry, PVR, and questionnaires. Patients underwent endoscopic and/or radiographic evaluation of urethral patency between 6 and 12 months postoperatively and assessment of urinary flow rate, IPSS, and voiding complaints. Continence Preoperatively patients were categorized continent, incontinent, or unknown if patients had an SPC. Postoperative continence status was assessed 3 to 6 months postoperatively, at the first visit following catheter removal. Postoperatively, patients were categorized as either continent or incontinent. Patients who underwent subsequent artificial urinary sphincter placement had a cystoscopy prior to implantation to rule out recurrence. Patient-Reported Outcomes PROMs, measured by validated questionnaires, qualitatively assessed postoperative satisfaction and durability. IPSS-QOL domain evaluated the patient perception of urinary symptoms and subjective durability. SHIM assessed erectile function. All patients were assessed preoperatively and those with no or mild erectile dysfunction (SHIM >16) were assessed postoperatively.19 The GRA is an externally validated questionnaire which assesses patients' impression of change in symptoms following urologic treatment, scores ranged from −3 (markedly worse) to +3 (markedly improved).20 Due to variations between institutions reported PROMs were assessed preoperatively and at last follow-up. Statistical Analysis Kaplan-Meier curves and the log rank test were used to evaluate recurrence. For cases that recurred, time to recurrence was the follow-up time when recurrence was noted. Patients who did not recur were censored at time of last follow-up. Of particular interest was whether there was a difference in recurrence by location or timing. Due to the small number of recurrences, additional recurrence-free analysis was not conducted. Patients with pre- and postoperative PROMs were analyzed. Continuous outcomes were assessed using a paired t test or Wilcoxon signed rank test, depending on normality. Binary categorical outcomes were evaluated using McNemar's test. Bowker's symmetry test was used to assess continence pre- vs postoperative as continence was a 3-level outcome, allowing for unknown status. P value < .05 was considered statistically significant for all analyses. All statistical analyses were performed using SAS version 9.4. Results Forty-five urethroplasties were performed by 8 surgeons between 2013 and 2021; median follow-up in patients without recurrence was 21 months (IQR 12-24). Patient demographics, cancer treatments, and stricture information are summarized in Table 1. Patients had a median of 2 failed prior dilations (IQR 1-3) and median of 1 prior DVIU (IQR 0-3). Perioperative Outcomes Median surgical time was 180 minutes (IQR 145.3-240), and median length of stay was 1 day (IQR 1-2), including 19 (50%) patients returning home within 23 hours after surgery. Median estimated blood loss was 100 cc (IQR 50-200 cc). All repairs were completed through a perineal incision without urethral transection, corporal body separation, partial pubectomy, flap interposition, or conversion to abdominoperineal incision. Postoperative complication rates are shown in Table 2. One patient who presented to the emergency department with a low-grade fever was discharged home after evaluation. There were 4 Clavien-Dindo grade 2 complications: 2 required antibiotics for infections, 1 was transfused for anemia, and 1 needed anticoagulation infusion for a venous thrombotic event. The patient who received the transfusion was in the first quartile of surgical blood loss ( 3 wk 4 (9) Uroflow, mean (SD) 6.1 (4.4) 14.46 (5.8) 8.35 (5.5, 11.2) < .0001 PVR, mean (SD) 162.54 (137) 61.88 (99.1) −100.7 (−143.9, −57.4) < .0001 SUI status, No. (%) .07 Continent 10 (22) 15 (331) Incontinent 29 (64) 30 (66) Unknown 6 (13) 0 AUS placed, No. 17 Patient-reported outcomes IPSS, mean (SD) 22.32 (8.3) 7.64 (6.4) −14.68 (−19.0, −10.4) < .0001 IPSS-QOL, median (IQR) 5 (4-6) 2 (1-3) −3 (−3, −2) < .0001 SHIM, No. (%), 26 patients 22-25 0 0 17-21 2 (8) 2 12-16 1 (4) N/A 8-11 2 (4) N/A 0-7 21 (84) N/A GRA, No. (%), 27 patients +3 N/A 17 (44) +2 N/A 6 (16) +1 N/A 1 (2.6) 0 N/A 1 (2.6) −3 N/A 2 (5.3) Spraying/stream deviation, No. (%) 4 (25) 3 (19) 0.06 (−0.15, 0.27) .56 Postvoid dribble, No. (%) 11 (69) 5 (31) 0.38 (0.08, 0.67) .034 Abbreviations: AUS, artificial urinary sphincter; ED, emergency department; GRA, Global Response Assessment; IPSS, International Prostate Symptom Score; N/A, xxx; PVR, postvoid residual; QOL, quality-of-life domain; SHIM, Sexual Health Inventory for Men; SUI, stress urinary incontinence. Continuous outcomes were assessed using a paired t test or Wilcoxon signed rank test. Categorical outcomes were evaluated using the McNemar's test for 2-level outcomes. Postoperative Surgical Outcomes Seven recurrences were identified, and the median time to recurrence was not defined because the probability of being recurrence-free remained above 50% throughout follow-up period (Figure 2). At the time of this publication only 2 patients experienced a recurrence after 1 year. We found no evidence of differences in recurrence rate based on stricture location (P = .65) or timing of prostatectomy (P = .13; Table 3). Median PVR and Qmax significantly improved postoperatively (P < .0001; Table 2). Figure 2. Recurrence-free survival curve. There was a total of 7 events. The median time to recurrence is not defined as the probability of recurrence never reached 50%. Table 3. Recurrence-Free Survival Estimates Probability of recurrence-free survival 12 mo (95% CI) 36 mo (95% CI) P value (log rank test) Overall 0.87 (0.76, 0.98) 0.79 (0.66, 0.94) Location .65 Bulbomembranous 0.95 (0.85, 1.0) 0.79 (0.57, 1.0) VUAS 0.79 (0.60, 0.97) 0.79 (0.6, 0.97) Timing of prostatectomy .13 Primary 0.88 (0.77, 0.99) 0.83 (0.7, 0.97) Salvage 0.75 (0.33, 1.0) a Abbreviations: VUAS, vesicourethral anastomotic stenosis. No patients in the salvage prostatectomy cohort were still at risk at 36 months. Pre- and postoperative continence is summarized in Table 2. We were unable to demonstrate D-BMGU resulted in a difference between pre- and postoperative continence (P = .07). There were zero incidents of de novo SUI. One previously incontinent patient reported regaining continence and 4 SPC-dependent patients were continent following repair. Seventeen of the 27 men (40%) with postoperative incontinence had an artificial urinary sphincter placement after urethroplasty. Patient-Reported Outcomes Preoperative and postoperative PROMs are summarized in Table 2. Postoperative PROMs were assessed at last follow-up: 12 were ≤ 12 months, 22 were between 12 and 36 months, and 11 were > 36 months. Patients reported significant improvement in IPSS, IPSS-QOL, and postvoid dribble (P < .0001; Table 2). Twenty-three men (85%) reported a marked (+3) or moderate improvement (+2) on postoperative GRA questionnaire (Table 2). Two patients who reported marked worsening of symptoms postoperatively were both managed with an SPC preoperatively and were incontinent postoperatively. Two out of 25 patients (8%) had a preoperative SHIM > 16, and neither reported a change postoperatively. Discussion This multi-institutional study found durable urethral patency rates utilizing BMGU in a patient population that has undergone both surgical and radiation treatments for prostate cancer. We report high PROMs across all participating institutions. The dorsal surgical approach described here preserves the external sphincter, likely explaining the lack of de novo SUI observed. We demonstrate reproducibility of D-BMGU in a difficult to treat patient population and demonstrate reconstruction of such patients does not further deteriorate overall QOL. Instead, this multi-national experience delineates this technique to be reproducible in terms of peri- and postoperative outcomes even though surgeons had varying years of experience and operated in a variety of surgical settings. The literature for patients who have undergone both radical prostatectomy and radiation therapy is limited.21 Rates of posterior urethral stenosis following salvage treatments range from 3% to 10% in patients receiving adjuvant/salvage radiation therapy to 11% to 40% in patients undergoing salvage prostatectomy.3,6,22-24 It is accepted that salvage prostatectomy has a measurable positive impact toward cancer-free survival but with added deleterious consequences such as posterior urethral stenosis and urinary incontinence. The existing literature on reconstructive techniques in this population is limited to small single institutional series of patients with mixed etiologies (with and without radiation) and mixed surgical approaches (abdominal, abdominoperineal, and perineal) with some requiring aggressive auxiliary maneuvers.25,26 Previous publications report a median time to recurrence following repair of postradiation stenosis of 2 to 17 months.9,10,14,27 Applying a more rigid statistical approach that we hope to become the standard for reconstructive publications the median time to recurrence was not reached, confirming the durability of this approach. Additionally, our finding that only 2 recurrences occurred after 1 year, while not definitive, does add to the evidence that recurrence after repair of a postradiation stenosis occurs early. Likely due to the minimal manipulation of the rhabdosphincter in this population undergoing D-BMGU, there were no instances of de novo SUI. Additionally, we report acceptable 90-day complication rates and failure rates in this cohort compared to previous series' describing different treatment strategies in a similar population. For comparison, de novo SUI in postexcisional urethroplasty patients with prior radiotherapy can be as high as 40%, and radiated patients with recalcitrant postprostatectomy stenosis treated with endoscopic procedures were previously noted to have a de novo SUI rate of 18%.7,8,10,13,14 In sum, radiated postprostatectomy prostate cancer survivors have resultant poorer tissue integrity to the posterior urethra, sphincter, and pelvic floor. While, only 11 patients in our cohort (29%) were classified as continent preoperatively, each one of those patients was continent postoperatively, which is clinically significant, the D-BMGU approach minimizes any further disruption to these structures thus accounting for the improved outcomes in this large multi-institutional series. Specifically, D-BMGU avoids circumferential dissection around the urethra, disruption of the sphincter, and spares the bulbar arteries preserving all remaining blood supply to an already compromised area. This approach also eliminates the need for adjunctive procedures (pubectomy, crural splitting, rerouting, abdominal counter incision, gracilis or omental flaps) minimizing the morbidity of the procedure and technical complexity. The dorsal urethral dissection also avoids an incision directed toward the rectum which in the setting of a previously radiated and operated pelvis would carry significant risk of rectal injury. Though this series demonstrates acceptable functional outcomes following perineal repair, some have demonstrated the robotic approach to have equally promising results in VUAS patients.28,29 Further, some have suggested the robotic approach may confer greater visualization and dexterity in an already narrow space around the bladder neck. Importantly, however, many of these prior investigations have been limited due to the exclusion of patients with a history of radiation. In the only assessment to date assessing feasibility of robotic VUAS repair in radiation patients, an honest accounting of results revealed concerningly poor outcomes including longer operative times, higher rates of incontinence, low success rates, and a high rate of reintervention, compared to nonradiated counterparts.28 The procedure described in this report could be technically difficult in patients where the bladder neck is not funneled and advanced anteriorly toward the membranous urethra. It could be perceived especially challenging to place the 3 apical anchoring sutures of the graft in an already narrow field due to all patients having a prior history of scarred planes due to radiation. Nevertheless, contemporary aids in visualization utilized by prior urethral reconstructionists such as the urethral gorget and nasal speculum were utilized by this multi-institutional group of reconstructive surgeons to assist with suture placement, thus demonstrating the generalizability of the technique. Any perceived challenge in executing a D-BMGU in this patient population is mitigated with the conferred advantages of improved continence and patient satisfaction. Historical works advocated for indefinite, intermittent endoscopic management in patients with VUAS and prior radiation.3 This may have been due to the significant risk of postoperative complications or the presumption that a previously radiated field resulted in poor graft bed conditions which subsequently yielded worse outcomes.14,30 More recent investigations have demonstrated the success rate of BMG urethroplasty for radiation-induced stenosis to be comparable to the success rate of nonradiation strictures.27,31 Our findings add to the growing literature that BMG can survive even in the most hostile graft beds. This technique has one major limitation: it cannot be used in the setting of an obliterative stenosis or anastomotic disruption. All 46 patients initially identified had nonobliterative stenosis, which at least allowed the passage of a guidewire across the stenotic segment. However, over the course of the study period, only 5 patients, not included in this study, presented with either an obliterative stenosis or anastomotic disruption and required excision and primary anastomosis urethroplasty. It should be noted that patients who are poor surgical candidates, have a small-capacity bladder (<100 cc), fistula, and/or radionecrosis would not be offered this reconstructive procedure. The retrospective nature along with the implementation of the D-BMGU technique at varying times with different surgeons of this study potentially introduces selection bias, and we are unaware of the number of patients who were offered this reconstruction but did not undergo the procedure. The process of obtaining PROMs varied between institutions, which may have introduced additional selection bias. Additionally, the effect of the procedure on erectile function was unable to be assessed given 92% of the cohort had moderate or severe erectile dysfunction preoperatively. Though it should be noted that the 2 patients with good erectile function preoperatively were found to have no decrease in postoperative SHIM. Longer follow-up is needed to verify the durability of this technique, but our results showing that of the 36 patients with follow-up greater than 12 months only 2 experienced a recurrence after 1 year add to the growing evidence that recurrences in this population occur early. Nevertheless, we demonstrate the D-BMGU in radiated postprostatectomy patients to have acceptable outcomes with excellent patient satisfaction. Conclusions D-BMGU is safe, feasible, and, at an intermediate-term follow-up, effective technique in patients with urethral stenosis after both prostatectomy and radiation therapy. Our findings suggest the D-BMGU technique may result in low rates of de novo SUI. Head-to-head comparisons with excisional urethroplasty techniques are necessary to help further delineate suggested continence benefit in a larger population. 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Crossref, Medline, Google Scholar Recusal: Dr Maranchie, assistant editor of The Journal of Urology®, was recused from the editorial and peer review processes due to affiliation with the University of Pittsburgh. Funding/Support: None. Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose. Ethics Statement: In lieu of a formal ethics committee, the principles of the Helsinki Declaration were followed. Author Contributions: Conception and design: Sterling, Nikolavsky. Data collection: All authors. Data analysis and interpretation: Sterling, Patel, Higgins, Swerdloff, Nikolavsky. Manuscript drafting, revision: Sterling, Simhan, Flynn, Patel, Nikolavsky. Approval of version to be published: All authors. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.© 2024 The Author(s). Published on behalf of the American Urological Association, Education and Research, Inc.FiguresReferencesRelatedDetails Advertisement Copyright & Permissions© 2024 The Author(s). Published on behalf of the American Urological Association, Education and Research, Inc.Keywordsreconstructive urologysalvage prostatectomypost-radiation stricturesbuccal mucosal urethroplastyvesicourethral anastomotic stenosisMetrics Author Information Joshua Sterling Department of Urology, Yale School of Medicine, New Haven, Connecticut Department of Urology, SUNY Upstate Medical University, Syracuse, New York More articles by this author Jay Simhan Department of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania More articles by this author Brian J. Flynn Division of Urology, University of Colorado School of Medicine, Aurora, Colorado More articles by this author Paul Rusilko Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania More articles by this author W. A. Franca Department of Urology, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil More articles by this author Erick A. Ramirez Hospital Angeles Mocel, Mexico City, Mexico More articles by this author Javier C. Angulo Department of Medical Clinic, Universidad Europea de Madrid, Madrid, Spain More articles by this author Francisco E. Martins University of Lisbon, Hospital Santa Maria, Lisbon, Portugal More articles by this author Hiren V. Patel Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey More articles by this author Margaret Higgins Division of Urology, University of Colorado School of Medicine, Aurora, Colorado More articles by this author Daniel Swerdloff Department of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania More articles by this author Dmitriy Nikolavsky Department of Urology, SUNY Upstate Medical University, Syracuse, New York *Corresponding Author: Dmitriy Nikolavsky, MD, Department of Urology, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210 E-mail Address: [email protected] More articles by this author Expand All Recusal: Dr Maranchie, assistant editor of The Journal of Urology®, was recused from the editorial and peer review processes due to affiliation with the University of Pittsburgh. Funding/Support: None. Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose. Ethics Statement: In lieu of a formal ethics committee, the principles of the Helsinki Declaration were followed. Author Contributions: Conception and design: Sterling, Nikolavsky. Data collection: All authors. Data analysis and interpretation: Sterling, Patel, Higgins, Swerdloff, Nikolavsky. Manuscript drafting, revision: Sterling, Simhan, Flynn, Patel, Nikolavsky. Approval of version to be published: All authors. Advertisement Advertisement PDF downloadLoading ...
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