Page 25 - Read Online

Page 8 of 11 de Toledo et al. Plast Aesthet Res 2022;9:5 https://dx.doi.org/10.20517/2347-9264.2021.103

Figure 1. Dorsal onlay buccal graft urethroplasty. (A) Semilunar suprameatal incision; (B) dorsal dissection; (C) 4 cm × 2cm buccal
graft; (D) apical fixation of graft; (E) neomeatus matured. Photos courtesy of Dr. DeLong.

Special situations
Within the iatrogenic causes of FUS, extra care needs to be taken with patients who have undergone pelvic
radiation. As in their male counterparts, urethral strictures caused by radiation are often more complex to
diagnose and treat. These patients may benefit from urodynamic evaluation to better elucidate symptoms
when appropriate. There is little data regarding radiated FUS because most authors exclude them from
their series. Gomez et al. report that both of their radiated patients undergoing urethroplasty failed and
[46]
suggest maximizing a conservative approach with these patients. If local tissue is of poor quality, a Martius
flap may be utilized to provide a healthy graft bed.

Patients with urethral stricture and concomitant stress urinary incontinence are rare. In these cases, we
advocate performing a continence procedure at the same time as the urethroplasty, or at interval if
preferred. In our practice, we treat the stricture with a dorsal buccal mucosa graft urethroplasty, and the
stress urinary incontinence with a pubovaginal sling. Martius flap may be utilized if needed.

Some authors suggest that interposition of a Martius flap should be done in all cases when performing a
ventral onlay buccal mucosa graft urethroplasty because it provides a healthy vascular base for the graft,
prevents urethrovaginal fistula development and provides healthy tissue between the reconstructed urethra
[2]
and the overlying vagina to facilitate any future surgery for subsequent SUI .
Suprapubic tube placement pre, intra or postoperatively can be considered. In some cases, such as
obliterative strictures, particularly in radiated patients, antegrade access is helpful. If the stricture is
obliterative, kissing grafts (dorsal and ventral) may be utilized. Lane et al. reported that 14% of patients
[25]
undergoing augment urethroplasty required a suprapubic tube placement preoperatively, and 14% of
patients intraoperatively. In rare cases, a suprapubic tube placement or formal urinary diversion should be
considered the definitive treatment if reconstructive alternatives fail .
[8]