UroToday - Traditionally, the treatment approach for short bulbar urethral strictures (1-2 cm) has been excision and primary urethral anastomosis (EPA) whereas longer strictures require substitution with grafts or flaps. A combination of the two techniques has gained popularity and the phrase augmented anastomotic urethroplasty (AAU) has been coined. This describes a technique where an obliterative or densely scarred area is excised, followed by anastomosis of the dorsal or ventral urethral wall. A graft or flap is then placed on the remaining wall to fill the urethrotomy defect.

Recently, a paper by Angermeier and colleagues from the Cleveland Clinic, examined a study cohort of 69 patients who underwent the AAU procedure. The report is published in the June 2007 issue the Journal of Urology.

Over an 8 period, 69 patients with a median age of 39 years underwent urethral reconstruction with the AAU technique for bulbar urethral strictures whose mean length was 4.2 cm as measured by pre-operative RUG. Ten percent (7 patients) had contiguous disease in the penile urethra. All patients had undergone prior incisions or dilations and 5 (7.2%) underwent prior failed urethroplasty using penile skin. In 58 patients (84%), the graft was placed ventrally, whereas in 11 (16%) it was placed in the dorsal position. These dorsal onlays were reserved for strictures involving the distal bulbar urethra or pendulous urethra, or when it was believed to have inadequate spongiosal tissue to support a ventral graft. The urethral catheter is left for 3 weeks at which point a VCUG is performed to assure patentcy and integrity of the repair.

At a median follow-up of 34 months, 62 patients remained asymptomatic and had no cystoscopic evidence of recurrent stricture for an overall success rate of 90%. Six of the 7 patients with evidence of recurrence had focal recurrences (5 at the proximal end of the repair) and one had diffuse repeat stricture. Median time to recurrence was 12 months. Three of the failures elected to have no treatment as they were asymptomatic, three responded to a single DVIU, and one failed a DVIU but has elected to forego any additional therapy as he is currently asymptomatic.

In conclusion, the AAU procedure, originally described by Webster, is an important tool for the reconstructive surgeon that is faced with an un-anticipated operative finding requiring a combination of urethroplasty techniques.

J Urol. 2007 June; 177(6):2211-16

Reported by UroToday Contributing Editor Michael J. Metro, M.D.

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