(349) A Unique Case of Bulbar Urethroplasty Using Distal Urethral Mucosa Autograft at the Time of Gender-Affirming Vaginoplasty

Introduction Urethral stricture disease presents significant challenges, particularly in recurrent or lichen sclerosus–associated cases where reconstructive options are limited. Substitution urethroplasty remains the main option, yet autologous graft materials are few, with buccal mucosa considered the gold standard. Gender-affirming penile-inversion vaginoplasty (PIV) is one of the few surgeries in which a distal urethral segment is discarded during urethral reconstruction. This presents a unique opportunity to use the patient’s own urethra as an autograft metrial for urethroplasty. Objective To present the first reported case (to our knowledge) of bulbar urethroplasty using distal urethral mucosa autograft, performed concurrently with PIV. Methods A 54-year-old transgender woman with a history of recurrent bulbar stricture since 2006 and lichen sclerosis (LS) presented in 2023 for PIV evaluation. Previous treatments included a buccal mucosal graft urethroplasty in 2010 and a cystoscopy with dilation in 2023. Repeat cystoscopy three months later revealed an 8-French stricture about 1 cm in length at the proximal bulb and an additional 1–2 cm of diseased urethra proximally. The distal urethra was unaffected. Given her interest in PIV, surgical options included a staged bulbar urethroplasty with buccal graft followed by PIV, or a combined surgery using either buccal or urethral autograft. Following detailed counseling regarding potential benefits, recurrence risk due to LS, and the experimental nature of the combined approach, she elected to proceed with the latter. Intraoperative findings and technique: Lichen sclerosis involved the scrotum and penis; cystoscopy confirmed preoperative findings. The vaginoplasty began in the standard fashion. After urethral shortening and spatulation, the urethra was sutured to the neo-clitoris to form a urethral plate. Spatulation was extended proximally to open the entire bulbar urethra and expose the stricture. The densest segment was incised dorsally and closed horizontally. A ventral inlay urethroplasty was completed using a 2 cm thinned section of the excised distal urethra; final urethral caliber was ≥18-French. The bulb was reconstructed in layers. Vaginal canal and introitus were constructed using mixed grafts of scrotal skin and tunica vaginalis, given partial LS involvement confirmed pathologically. A triangular perineal flap was created at the posterior fourchette. Limited penile flaps connected to the graft at the introitus achieved a 5-inch vaginal depth. A suprapubic tube and urethral catheter were placed; the suprapubic tube was removed at 4 weeks. Topical steroid ointment was initiated for LS management during dilation. Results Pathology confirmed lichen sclerosis. The patient experienced three urinary tract infections with urge incontinence that resolved with antibiotics. No obstructive symptoms were reported. At six months, cystoscopy showed a well-healed urethra without recurrent stricture. Uroflow was inconclusive due to low voided volume. Postoperative complications included wound dehiscence and partial distal vaginal graft failure at 4 weeks, followed by progressive vaginal stenosis and dilation cessation by six months. Conclusions LS remains a challenge for treatment of urethral stricture disease and genital surgery. This first reported case of concurrent PIV and bulbar urethroplasty using distal urethral mucosa autograft demonstrates the feasibility of combining both procedures in a single operation, potentially reducing surgical burden and morbidity in selected patients. Disclosure No