The Use of Buccal Mucosa in Bulbar Stricture Repair: Morbidity and Functional Outcome

Urethral stricture disease is as old as mankind. In the old times urethral strictures were mainly associated with longstanding infectious disease (gonococcal urethritis) or trauma (Beard and Goodyear, 1948). Current stricture aetiology in the developed world is mainly iatrogenic, such as strictures after (traumatic) urethral catheterization or transurethral resection, and idiopathic (Fenton et al., 2005, Lumen et al., 2009). Besides the aetiology of strictures, also the armamentarium to treat them has evolved. Repeated dilatation or, in complicated cases, external urethrotomy or cystotomy were the only treatment options for centuries instead of leaving the disease on its natural evolution. Today, optic urethrotomy, anastomotic urethroplasty and substitution urethroplasty offer better functional results, better cosmesis and in the majority of patients a permanent solution to the disease. Urethral strictures most frequently occur at the bulbar urethra (Lumen et al., 2009, Fenton et al., 2005, Meeks et al., 2009, Andrich and Mundy, 2008, Santucci et al., 2007). This is the part of the urethra that is surrounded by the corpus spongiosum and the bulbospongiosus muscle. When a bulbar stricture is encountered for the first time in a patient, a direct vision internal urethrotomy can be offered. This may be curative for short strictures in about half of the patients treated. Previous urethrotomy/dilatation or direct vision internal urethrotomy in longer strictures reduces success rates to almost zero (Pansadoro and Emiliozzi, 1996, Steenkamp et al., 1997). This does not mean that the patient cannot be managed this way, but the treatment is palliative in nature and repeat treatments or intermittent self catheterization will be mandatory to maintain patency. When these patients want to be cured from their stricture disease, an operative approach has to be offered. It is probably better to offer this approach sooner than later. From a surgical point of view, less spongiofibrosis will be found and from an economical point of view, early surgery is probably more cost effective (Rourke and Jordan, 2005, Greenwell et al., 2004, Andrich and Mundy, 2008, Wright et al., 2006). The operative approach can essentially be divided in anastomotic and substitution urethroplasties. In the first, a tension free, spatulated anastomosis is the key to success. This technique is generally advocated for shorter strictures that can be excised completely. It is assumed that results from end-to-end anastomotic urethroplasty are superior to substitution urethroplasty. This believe is partially based on intuition: excision of the diseased urethra and subsequent restoration of the continuity using healthy ends ‘has to be better’ then leaving the diseased urethra in place and augmenting it with another tissue. However, the