Mp22-07 outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Post-Prostatectomy, Post-Radiation Anastomotic Contracture

We appreciate the observations and acknowledgment of our work 1 by Drs Warner and Johnsen. Their editorials provide valuable insight into the evolving landscape of urological reconstructive surgery, especially concerning the use of grafting in radiated fieldsda practice once deemed contraindicated. 2 A reevaluation of the tenets of reconstruction, to see if they are truly foundational pillars for the future or relics of the historical past, is necessary for progress.Previously, radiation-induced strictures were considered to be more similar to traumatic urethral disruptions, which guided surgical management of these patients. [3][4][5] In our series, the occurrence of complete urethral obliteration was infrequent, noted in just 6 out of numerous cases referred to our centers. This finding underscores our belief that urethral obliteration is not a common end point for most cases of radiated posterior urethral stenosis.

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confidence: 82%

Reply by Authors

Sterling,

Simhan,

Flynn

et al. 2024

“…In this multi-institutional study, the authors present their technique and outcomes in managing patients with nonobliterative posterior urethral stenosis following both radical prostatectomy and radiation therapy for prostate cancer. 1 Utilizing a dorsal onlay buccal grafting approach, they were able to achieve success in 38/45 patients (84%), with no identifiable incidences of de novo stress urinary incontinence at a median follow-up of 21 months.…”

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confidence: 95%

“…Taken together, while this is a technically challenging operation, it should be accessible to most who are already performing posterior urethroplasty and should be considered a viable alternative to more traditional transecting approaches. Niels V. Johnsen 1…”

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confidence: 99%

Editorial Comment

Johnsen

2024

In this multi-institutional study, the authors present their technique and outcomes in managing patients with nonobliterative posterior urethral stenosis following both radical prostatectomy and radiation therapy for prostate cancer. 1 Utilizing a dorsal onlay buccal grafting approach, they were able to achieve success in 38/45 patients (84%), with no identifiable incidences of de novo stress urinary incontinence at a median follow-up of 21 months.This technique is potentially practice-changing for many of us who manage this difficult condition in that it changes how we think about appropriate graft beds for utilizing buccal mucosa in urethral reconstruction. For some time, it has been believed that grafts would not survive when transposed onto radiated fields such as those encountered in these patients. However, this study would suggest otherwise, with patients having intermediate-term success and patency similar to or even surpassing many series employing an anastomotic approach. Furthermore, avoiding transection of the bulbar arteries and limiting damage to the external urethral sphincter suggests the potential for improved

“…We commend the authors on their report of outcomes for dorsal onlay buccal mucosa urethroplasty in this fragile patient population. 3 The proposed technique confers an optimistic 85% success rate where complications were infrequent. This is inconsistent with previously reported surgical reconstruction outcomes in this patient population using a combined robotic and perineal approach; the results are humbling (including our own) and did not reflect the outcomes of this multi-institutional series.…”

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confidence: 99%

Letter: Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

Pinkhasov,

Viers

2024

contributing factor to the overall complications. The concerns about our very inclusive composite complication rates can be overcome by selecting one's favorite components from Table 3 in the manuscript, which lists all confirmed and suspected infectious complications. The importance of understanding the definition of an infection is exemplified by the study referenced by the authors as having low infection rates, 5 which reported only the rate of prostatitis. It seems implausible that no patient experienced any postbiopsy fever, voiding symptoms, dysuria, other UTIs, or hospital visit.The location of prostate biopsy procedure, ie, in office or in the operating room, is more reflective of local practice patterns and resources. It is unlikely to play a role in reducing infectious complications because the act of inserting needles into the genitourinary tract is an inherently contaminated procedure. Regardless, nearly 3 decades of worldwide experience with the inoffice prostate biopsy would suggest that performing this procedure under sterile conditions is unnecessary and costly.The concern about sepsis rates and sample size of our study is misplaced as our RCT was not designed to study the effect on sepsis rates, but rather on all major and minor infections. Investigators who wish to study sepsis outcomes will need to conduct such a trial, with sepsis as the prespecified outcome. The systematic review by Bennett et al is seductive due to its large population (>165,000 patients). 6 This and other studies are often used by proponents as an example of low sepsis rates after transperineal prostate biopsy while selectively omitting the 4-fold increase in urinary retention or hospital admissions reported in the same studies. 7 A closer examination of that study reveals that the tremendous heterogeneity in the pooled data (technique, prophylaxis, and definitions of outcomes) was such that none of the reported differences in outcomes were statistically significant. Thus, retrospective, heterogenous, observational cohort studies cannot supplant the results of randomized controlled trials.