Anterior urethral strictures can be divided as iatrogenic, inflammatory, idiopathic, and traumatic based on their etiology. The most common reason in developed countries is iatrogenic and idiopathic and the most common reason in developing countries is lichen sclerosis. Iatrogenic strictures mostly occur secondary to urethral catheterization, prostatectomy, cystoscopy, and hypospadias repair in advanced-age patients while idiopathic strictures often occur in adolescents and young men. Mostly, patients initially present with split urine stream during micturition and post-micturition dribble. Additionally, patients may also present with urinary tract infections, orchitis, and bladder calculi. Ejaculation disorders are rarely seen in urethral strictures. There are many modalities of surgical methods in urethroplasty surgery and which method is applied is decided according to the length and localization of the narrow segment. Currently buccal mucosa flaps most frequently are preferred in urethral surgery. Management of bulbar urethral strictures, ventral onlay buccal mucosa urethroplasty is one of the treatment options.

In this video presentation, we aimed to demonstrate the stages of the ventral onlay buccal mucosa urethroplasty in a patient who had anejaculation problem due to recurrent bulbar urethral stenosis developed after urehral catheterization.

A 34-year-old male patient presented to our clinic with anejacolation. In the patient's medical history he was diagnosed with chronic renal failure 19 years ago and had renal transplantation twice. Hemodialysis has been performed 3 times a week for 3 years. There was no urine output for 2 years. There was a history of multiple urethral catheterization during this period. Urethral dilatation was performed 3 times during this period and ejaculation improved after these treatments. He noticed that urethral stenosis was re-occurring when his ejaculation started to decrease. Spermiyogram failed for lack of ejaculation. In retrograde urethrography, approximately 2 cm stenosis was observed in the bulbar urethra. Cystourethroscopy performed on the patient revealed a 2 cm stenosis starting 2 cm distal to the sphincter. It was decided to perform buccal mucosal graft urethroplasty. A 3 cm buccal mucosa graft was applied to the urethra by a vetral approach. The operation time was 120 minutes and blood loss was 30 cc. The patient, who did not have any additional problems during follow-up, was discharged on the 3th postoperative day. Urethral catheter was removed on the 21st postoperative day. In the 3th month controls, ejaculate volume 1.5 ml - sperm concentration 26 million / ml — total sperm count 39 million — total progressive motile sperm number 15 million / progressive movement 38% / kruger normal 2% was found.

Different surgical techniques have been defined in urethral stricture surgery. When deciding on the surgical technique factors such as the location and length of the stenosis should be taken into consideration and the surgeon's experience also has a very important place. Each surgical technique has its own advantages. Therefore, it is very important to master the anatomy of the urethra and different surgical techniques to increase the rate of surgical success. The introduction of buccal mucosal graft in urethroplasty surgery has brought a different dimension to surgical techniques and significantly increased the rate of surgical success. Ventral onlay urethroplasty is advantageous as it provides relatively better exposure of proximal anastomotic site and requires less urethral dissection. However, it can also be disadvantageous due to its higher risk of fistula formation associated with its weak support tissue and due to greater blood lossassociated with its large spongious tissue.
Vetral onlay urethroplasty can be used as a safe and effective method in the treatment of recurrent bulbar urethral stenosis.