The Impact of Surgical Sequence on Stricture Recurrence after Anterior 1-Stage Buccal Mucosal Graft Urethroplasty: Comparative Effectiveness of Initial, Repeat and Secondary Procedures

PURPOSE: We compared the results of initial buccal mucosal graft urethroplasty to the results of repeat and secondary cases of previous urethroplasty done by any technique other than buccal mucosal graft urethroplasty.

MATERIALS AND METHODS: We performed a retrospective study of patients who underwent buccal mucosal graft urethroplasty between January 2009 and December 2016 at a high volume center. Patients were stratified according to surgical sequence and characteristics were compared. We plotted Kaplan-Meier curves to compare stricture recurrence-free survival according to the surgical sequence. Multivariable Cox regression analyses were performed to delineate the impact of the surgical sequence on recurrence-free survival after adjusting for known clinical and surgical confounders.

RESULTS: Of 534 men with a median followup of 33 months (IQR 17-52) 436 (81.6%), 64 (12.0%) and 34 (6.4%) underwent an initial, a repeat and a secondary procedure, respectively. Patient characteristics were comparable (each p ≥0.2). Patients with reoperative procedures had received more previous endoscopic interventions and were more often operated on by high volume surgeons (each p ≤0.021). Operative time, graft length, stricture location and surgical techniques were comparable (each p ≥0.1). The success rate of initial, repeat and secondary procedures was 87.4%, 87.5% and 70.6%, respectively. On survival analyses patients who underwent secondary procedures fared worse than those who underwent repeat or initial procedures (p = 0.010). Similarly a secondary procedure was an independent risk factor for recurrence (HR 2.42, 95% CI 1.03-5.68, p = 0.043).

CONCLUSIONS: We found excellent results for repeat anterior 1-stage buccal mucosal graft urethroplasty, comparable to those of initial procedures. Patients who underwent secondary procedures were at higher risk for recurrence. However, when performed at a specialized center, the success rate was still high.