Excisional urethroplasty and the abdominoperineal approach to posterior urethral stenosis: surgical techniques and considerations for the radiated patient

Pelvic radiation is associated with significant long-term genitourinary toxicity, with a cumulative incidence of urethral stricture following primary prostate radiation of nearly 20%. While there are a variety of techniques for posterior urethral reconstruction in the setting of prior pelvic radiation therapy, excisional urethroplasty remains a mainstay of treatment. Complete scar excision with primary anastomosis (EPA) for posterior stricture below the pelvic floor and a combined abdominoperineal approach for those extending above the pelvic floor are two reconstructive techniques for managing this complex pathology. Reconstructive success, defined as urethral patency on cystourethroscopy, for EPA is between 70-87%; however, the risk of <i>de novo</i> stress urinary incontinence (SUI) approaches 20%. The combined abdominoperineal approach presents one of the more complex techniques for lengthier strictures, involving extensive mobilization of the urethra in order to achieve a tension-free anastomosis. Overall complications, including risk of persistent leak and fistula, are higher with this approach, and there is a greater risk of needing repeat endoscopic intervention for recurrence. Both of these transecting techniques for posterior urethroplasty pose an increased risk of future artificial urinary sphincter erosion, especially in the context of prior radiation therapy. Herein, we describe our standard practice for preoperative evaluation of radiation-induced posterior urethral reconstruction, techniques for excisional urethroplasty, and postoperative pathways.