Gracile muscle flap reinforced buccal mucosa (GMRB) neourethra: One stage repair of posterior urethral stricture

Posttraumatic stricture of the posterior urethra is a great challenge and still much debate exists regarding the method of correction. We report a case of successful correction using buccal mucosa and gracilis muscle. A 34 year old male who sustained multiple injury including intraperitoneal hemorrhage, clavicle and pubic fracture, and complete posterior urethral rupture. Immediate exploration and suprapubic urinary diversion were performed. End-to-end urethroplasty after 3 months resulted in failure, and another attempt of internal optical urethrotomy also failed. Combined cystourethrogram revealed complete discontinuity of posterior urethra with defect of 3 cm. An inverted Y incision is made at perineum and deepened to the layer of bulbospongiosus muscle. Bulbar urethra was disscted. Bladder neck was exposed with further dissection. Severe fibrosis was encountered and the anastomosis without tension was not possible. To achieve tension free anastomosis a 3 × 4 cm sized full thickness buccal mucosa was harvested and trimmed. Oral cavity was packed with vaseline gauze. Mucosal flap was tubularized with 16 Fr catheter. Flap was anastomosed with bladder neck with vicryl 3-0 interruptedly and distal urethral continuity was achieved in similar fashion. To cover the defect after removing fibrosis and exposing fresh perineal tissues, well-vasularized gracilis muscle was harvested from left inner thigh. Muscle was freed and transferred to the perineum via subcutanous tunnel. Neourethra and perineal space is well interposed with gracilis muscle flap. After confirming patency without extravasation on pericatheter urethrogram, catheter was removed 3 weeks after operation. Self voiding of 300 - 400 cc with the forceful stream of urine was observed. Uroflowmetery with maximal flow rate of 16.8 ml/sec was observed. Incontinence or other voiding symptoms were not observed. In conclusion, buccal mucosa with gracilis muscle flap interposition is a highly successful and viable option in cases of refractory posterior urethral stricuture with compromised vascular bed and long urethral defect.