Emerging technique for posterior endoscopic urethroplasty with graft

To describe a novel surgical technique for endoscopic posterior urethroplasty using buccal graft. Patient 1 is an 80-year-old male with benign prostatic hyperplasia status post transurethral resection and Greenlight laser vaporization of the prostate complicated by bladder neck contracture who has been suprapubic tube dependent for years. Patient 2 is a 70-year-old male with prostate cancer status post robotic radical prostatectomy with salvage radiation with multiple prior endoscopic treatments for vesicourethral anastomotic scar. Surgical procedure involved cystoscopy to identify the stenotic area. A transurethral resecting loop was then utilized to establish a shallow trough for the graft. A buccal graft was harvested in the typical fashion and Dermabond was applied to the mucosa surface to prevent curling. Next, we placed stitches on the corner of the graft for ease of endoscopic maneuvering. We used a grasper at the tip of a rigid cystoscope to deliver the graft to the shallow trough. An endoscopic “sewing machine” was prepared by pre-loading a Williams botox with barbed suture. With the graft placed over the bed, we used the cystoscope and preloaded barbed suture to quilt the graft to the urethral bed. This was repeated until the graft appeared immobile. A 16-French Foley catheter was left in place for two weeks. There were no complications during both procedures. For patient 1, cystoscopy two weeks post-op demonstrated pink graft in contact with the urethral floor. There was an open channel to the bladder. For patient 2, post-op cystoscopy was delayed to six weeks post-op due to persistent pain. Cystoscopy showed no obstructive areas and a widely patent urethra. Patient 1 was able to continue to void per urethra for 3 months before stricture recurrence occurred. Patient 2 is still voiding per urethra at 12 months post-op and his urethra remains patent at the time of this manuscript submission. Endoscopic posterior urethroplasty using buccal graft is a viable minimally invasive approach but refinements are still needed. We anticipate additional innovations in this space as the field moves to more minimally invasive techniques.