Successful BMG Urethroplasty for Bulbar Urethral Stricture in 55-Year-Old Male

PACE Hospitals

The PACE Hospitals' expert Urology team successfully performed a Buccal Mucosal Graft (BMG) Urethroplasty on a 55-year-old male patient who presented with poor urine flow. The procedure was aimed at reconstructing and widening the narrowed section of the urethra using tissue from the inner cheek (buccal mucosa), thereby restoring normal urinary flow, relieving symptoms, and preventing future complications.

Chief Complaints

A 55 -years- old male patient with a Body Mass Index (BMI) of 23 presented to the Urology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of poor urine flow.

Past Medical History

The patient had a history of near urinary retention, for which a suprapubic catheter (SPC) was placed elsewhere to relieve the obstruction and ensure proper bladder drainage.

On Examination

On examination, the patient was alert, oriented, and hemodynamically stable, with vital signs within normal limits. The abdomen was soft, with no palpable bladder distension or tenderness. The suprapubic catheter (SPC) site appeared clean and intact, with no signs of infection or leakage. Examination of the external genitalia was normal, showing no visible abnormalities or inflammation. A digital rectal examination revealed a mildly enlarged but non-tender prostate. No inguinal lymphadenopathy was noted.

Cardiovascular system (CVS) examination showed normal heart sounds with no murmurs. The rest of the systemic examination was normal.

Diagnosis

The patient initially underwent a comprehensive clinical assessment at PACE Hospitals, including a detailed history and physical examination by the Urology team. During the evaluation, a series of diagnostic tests were performed.

The patient underwent uroflowmetry, which revealed a reduced urine flow rate consistent with urethral obstruction. Ultrasound of the kidneys, ureters, and bladder showed bladder wall thickening and a significant post-void residual volume. A retrograde urethrogram confirmed a long-segment bulbar urethral stricture, likely secondary to a previous TURP procedure. Blood tests indicated diabetes mellitus, with elevated blood glucose and HbA1c levels, while repeated blood pressure measurements confirmed hypertension. Cardiac evaluation, including ECG and echocardiography, was unremarkable. The urine culture tested positive, indicating a urinary tract infection that required appropriate management.

Based on the confirmed findings, the patient was advised to undergo Bulbar Urethral Stricture Treatment in Hyderabad, India, under the expert care of the Urology Department.

Medical Decision Making

Following a detailed consultation with Dr. Vishwambhar Nath, Senior Consultant Urologist & Renal Transplant Surgeon, and Dr. Abhik Debnath, Consultant Laparoscopic Urologist, a comprehensive evaluation of the patient’s condition was conducted. Considering his symptoms of reduced urine flow consistent with urethral obstruction, imaging findings of a short-segment bulbar urethral stricture, and a positive urine culture indicating infection, the urology team determined that buccal mucosal graft (BMG) urethroplasty would be the most suitable and effective intervention after appropriate infection management.

The patient and his family were thoroughly counselled regarding the severity of the condition, the details of the surgical procedure, potential risks, and the necessity of the procedure to restore function and promote optimal recovery.

Surgical Procedure

Following the decision, the patient was scheduled to undergo a Buccal Mucosal Graft (BMG) Urethroplasty Surgery in Hyderabad at PACE Hospitals, under the expert supervision of the Urology Department, ensuring optimal care and a smooth recovery process.

The procedure was performed in the following steps:

1. Anesthesia and Identification: The procedure was performed under general anesthesia. The patient had a long-segment bulbar urethral stricture with multiple false passages. Retrograde and antegrade scopy, along with methylene blue dye and a Terumo guide wire, were used to locate the correct urethral passage.

2. Surgical Access: A perineal incision was made to expose the affected bulbar urethra.

3. Urethrotomy and Graft Placement: A ventral urethrotomy was performed along the stricture, and a buccal mucosal graft (BMG) was placed over the strictured segment.

4. Catheter Insertion: An 18 French silicone Foley catheter was inserted to maintain urethral patency.

5. Graft Fixation and Reinforcement: The graft was secured with reverse quilting, followed by spongioplasty to support and promote healing.

Postoperative Care

His intraoperative and postoperative course was uneventful, with no complications observed during or after the surgery. During his hospital stay, the patient was treated with intravenous antibiotics, analgesics, proton pump inhibitors (PPIs), and other supportive medications to promote recovery and prevent infection. He remained stable throughout and was discharged in good condition with the urinary catheter left in place to ensure proper healing and urinary drainage.

Discharge Medications

Upon discharge, the patient was prescribed a course of intravenous antibiotics to prevent infection due to the presence of multiple false passages in the urethra and his diabetes mellitus. He was also given oral antibiotics to continue infection control, along with pain relievers to manage discomfort and fever as needed. To protect his stomach, a proton pump inhibitor was included in his medication regimen. Additionally, a multivitamin supplement was recommended to support overall recovery and health. For management of his hypertension and diabetes, appropriate medications were prescribed to control blood pressure and blood sugar levels effectively.

Advice on Discharge

The patient was advised to take sitz baths twice daily for three weeks and to follow daily wound dressing as instructed for the same duration. He was also instructed to keep the local area clean and maintain proper hygiene. Additionally, mouth exercises were recommended as part of the recovery process. Walking and regular ambulation were encouraged to promote overall healing and prevent complications.

Dietary Advice

The patient was advised to follow a low-salt, diabetic-friendly diet, avoid hot and spicy foods, and consume a soft diet to support recovery and manage his health conditions effectively.

Emergency Care

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms like fever, abdominal pain, or vomiting.

Review and Follow-up Notes

The patient was advised to return for a follow-up visit with a Urologist in Hyderabad at PACE Hospitals, after one month for removal of the per urethral Foley catheter. Additionally, he was instructed to consult his local physician after one month and provide fasting blood sugar (FBS), postprandial blood sugar (PPBS), and HbA1c reports. The suprapubic catheter (SPC) removal was scheduled for one week later at his hometown.

Conclusion

This case highlights the effective surgical management of a long-segment bulbar urethral stricture with multiple false passages using buccal mucosal graft urethroplasty. The patient had a smooth recovery with no postoperative complications. Continued follow-up is essential for catheter care and control of underlying conditions.

Buccal Mucosal Graft Urethroplasty in a High-Risk Patient with Complex Urethral Stricture

Effective management of a long-segment bulbar urethral stricture with multiple false passages requires an integrated approach combining precise diagnostic tools and expert surgical planning. Identifying the true urethral lumen using antegrade and retrograde scopy with dye assistance ensures accurate intervention.

Buccal mucosal graft urethroplasty offers a reliable reconstructive solution, especially in complex cases. Postoperative care, including infection control, glycemic and blood pressure management, and catheter maintenance, is critical for recovery. Timely follow-up for catheter removal and monitoring of metabolic parameters helps prevent complications. The urologist/urology doctor plays a central role in coordinating this multidisciplinary strategy, providing patient education, and ensuring ongoing care for long-term success and improved quality of life.