DORSAL ONLAY GRAFT URETHROPLASTY USING PENILE SKIN OR BUCCAL MUCOSA IN ADULT BULBOURETHRAL STRICTURES

The oral mucosa graft: a systematic review

PURPOSE

We provide the reader with a critical, nonbiased, systematic review of current and precedent literature regarding the use of oral mucosa in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias.

MATERIALS AND METHODS

We reviewed pertinent English literature from January 1966 through August 1, 2006 via the databases MEDLINE/PubMed, the Cochrane Library, and EMBASE Drugs and Pharmacology regarding the use of oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias. Bibliographies of pertinent articles were explored for additional important literature.

RESULTS

Data were stratified among studies that only used oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with stricture, and those that used oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with hypospadias/epispadias. Recipient site success in the reconstruction of defects associated with stricture was significantly associated with the location of graft placement (ventral vs dorsal, p <0.001) when an onlay graft was used. Hypospadias/epispadias recipient site success was significantly associated with the type of graft used (tube vs onlay, p <0.001), and by the site of oral mucosa harvest (labial vs buccal, p <0.001). Other perioperative and patient oriented variables were not significantly associated with success at the recipient site.

CONCLUSIONS

The oral mucosa is a viable source of donor tissue displaying many characteristics of the ideal urethral graft. There are numerous variations of the oral mucosa graft urethroplasty technique. Herein comparisons are made.

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction

OBJECTIVES

We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG).

METHODS

From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation.

RESULTS

Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy.

CONCLUSIONS

Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.

Dorsal onlay buccal mucosal graft urethroplasty in long anterior urethral stricture

OBJECTIVE

To assess the success of buccal mucosal graft (BMG) urethroplasty by the dorsal onlay technique in long anterior urethral stricture (> 2 cm long) through the midline perineal incision.

MATERIALS AND METHODS

From January 1998 to December 2003, 43 patients with long anterior urethral strictures were managed by dorsal onlay BMG urethroplasty. After voiding trial, they were followed up at 3 months with uroflowmetry, retrograde urethrogram (RGU) and American Urological Association symptoms score (AUA symptoms scores). Successful outcome was defined as normal voiding with a maximum one attempt of visual internal urethrotomy (VIU) after catheter removal. Patients were further followed-up with uroflowmetry at 3 months interval and RGU every 6 months interval.

RESULTS

Mean stricture length was 4.8 cm (range 3 to 9 cm) and mean follow up was 48 months (range 12 to 84 months). Only five patients were found to develop stricture at anastomotic site, during follow-up. Two of them voided normally after single attempt of VIU. Other three patients (6.9%) required further open surgery or repeat VIU during follow up and were considered as failure.

CONCLUSION

Dorsal onlay BMG urethroplasty is a simple technique with good surgical outcome.

Urethroplasty for anterior urethral strictures in a community-based urology practice

INTRODUCTION

The outcome of urethroplasty for the anterior urethral stricture is superior to internal urethrotomy. However, the excellent results are often reported by tertiary medical centres and most urologists in general urological practice do not offer urethroplasty. We review the results of our institution to ascertain whether equivalent results are achievable in a district hospital urology service.

METHODS

Over a 22-month period, 26 urethroplasties were performed. Mean age was 44.2 years (range: 16-83 years) and median follow-up was 14.6 months (range: 0.6-40.2 months). Anastomotic repair was performed in five, substitution urethroplasty in 15 (nine flaps and six grafts) and staged urethroplasty in 6. Length of strictures ranged from less than 0.2 cm to greater than 10 cm.

RESULTS

Stricture-free rate of 90.5% at 1 year was observed. Only two cases developed repeat stricture formation. Other minor complications included one epididymo-orchitis and one haematoma.

CONCLUSION

Good early outcome for urethroplasty for anterior urethral strictures is achievable in a district hospital practice. Keys to good outcome include having a dedicated team and a wide repertoire of urethral reconstructive techniques.

Dorsal on-lay preputial graft urethroplasty for anterior urethra strictures repair

OBJECTIVES

To report the long-term results and evaluate the effectiveness of the dorsal on-lay preputial graft urethroplasty in patients suffering from anterior urethra strictures.

METHODS

A total of 21 male patients, mean age 46.3 years (range 17-67), with anterior urethral strictures, underwent the dorsal on-lay preputial graft urethroplasty during the last 8 years, from October 1997 to September 2005. Strictures were located in bulbar urethra in 16 patients and in penile urethra in the remaining 5. The aetiology the stricture was traumatic injury of the anterior urethra in 12 patients and iatrogenic in 9 patients. A direct vision dorsal urethrotomy and the insertion of an urethral Foley catheter right before the procedure, facilitated the corpus spongiosum dissection and the preparation for urethroplasty. A voiding cystogram was performed on the day of urethral catheter removal to exclude extravasation and estimate the postoperative result.

RESULTS

Mean follow-up time has been 49.9 months (range 6-95) and the outcome was favourable in 15 patients (71.43%). There were 3 recurrences in penile urethra strictures managed conservatively and three in bulbar urethroplasties, treated with internal urethrotomy followed by urethral dilatations.

CONCLUSION

Our results indicate that dorsal on-lay urethroplasty using preputial graft is an easy to learn and perform procedure, and offers the patient durable results with rather minimal complications.

Giant Urethral Diverticulum – Unusual Complication following Ventral Buccal Mucosa Onlay Graft Urethroplasty

During the past 10 years, buccal mucosa grafting for urethroplasty has gained widespread acceptance. In general the reported success rates are 80% and higher. Typical complications are recurrent strictures, fistula, and, especially when the technique of ventral onlay urethroplasty has been used, sacculations that are of little clinical significance in most cases. The development of large diverticula has not been described yet. We report on the case of a 63-year-old man who developed a giant diverticulum of the urethra 1 year after a ventral buccal mucosa onlay graft urethroplasty for recurrent bulbar urethral strictures had been worked out.

Urethral reconstruction

PURPOSE OF REVIEW

To present an up-to-date review on the main surgical techniques used to treat urethral strictures.

RECENT FINDINGS

Anterior urethroplasty can be treated in outpatient surgical settings, thus decreasing the impact of urethroplasty. To improve outcome in adult patients, reconstructive surgeons have learned to apply the principles of hypospadias surgery, such as delicate tissue handling, avoidance of overlapping suture lines, tissue and the development of preputial skin flaps, to adult urethral surgery. Penile skin has been used as a free graft or harvested as a flap for some time, thanks to its location, hairless skin and durability. Since the early 1990s the use of buccal mucosa was introduced in genital reconstructive surgery and has become popular for complex urethral reconstructions. The use of fibrin glue was recently suggested to fix the buccal mucosal graft in a better way and to cover the anastomosis between the graft and urethral plate.

SUMMARY

Urethral reconstructive surgery is changing rapidly and this change has posed problems for surgeons who see the principles that previously defined their profession becoming obsolete or unworkable. New techniques, new tools, such as fibrin glue, and new engineered material are a part of our future.

Bulbar Urethroplasty with Dorsal Onlay Buccal Mucosal Graft and Fibrin Glue

OBJECTIVES

We describe a new surgical technique with the use of fibrin glue for bulbar urethra reconstruction using a dorsal buccal mucosal onlay graft.

METHODS

Six patients with a mean age of 43 yr underwent bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. The urethra was mobilised from the corpora cavernosa and opened along its dorsal surface. The buccal mucosal graft was applied on the corpora cavernosa using 2 ml of fibrin glue. Two interrupted polyglactin 5-0 sutures were used to fix the apices of the graft to the underlying albuginea of the corpora cavernosa. The urethra was rotated back to cover the graft and an adjunctive fibrin glue was injected over the urethra.

RESULTS

The mean operative time was 100 min (range, 90-120 min). No intraoperative or postoperative complications were observed. Voiding cystourethrography was performed when the catheter was removed 2 wk after surgery. Urine culture, uroflowmetry, and urethrography were repeated after 6 and 12 mo and annually thereafter. Mean follow-up was 16 mo (range, 12-24 mo). No restrictures at the anastomotic sites were demonstrated in any of the patients 6 and 12 mo after surgery.

CONCLUSIONS

The use of fibrin glue represents a slight but significant step toward perfecting the surgical technique of bulbar urethral reconstruction.

Small intestine submucosa in urethral stricture repair in a consecutive series

OBJECTIVES

To define the feasibility of acellular porcine small intestine submucosa (SIS) as a xenograft implant. SIS is commercially available and approved for use in humans.

METHODS

Five patients underwent open surgery for urethral stricture repair using SIS and a four-layer SIS graft. Two patients had a bulbar stricture and three had a combined penile-bulbar stricture. The median stricture length was 9 cm (range 3.5 to 10). All patients underwent at least one internal urethrotomy. The urethral stricture repair was performed as an onlay urethroplasty. SIS was used to augment the urethral caliber at the stricture site. A catheter and percutaneous cystostomy for drainage were placed. The catheter was removed 10 days after surgery. Three weeks postoperatively, voiding cystourethrography and retrograde urethrography were performed.

RESULTS

Preoperatively, flow studies were available for 3 patients, in 1 patient voiding was not possible because of urinary retention, and in 1 patient the preoperative flow study was not available (surgery was performed on the basis of the preoperative urethrographic findings). The mean maximal flow rate was 4.2 mL/s (n = 3); the mean value of the mean flow rate was 2.6 mL/s (n = 3). Postoperatively, 1 patient had extravasation, which was treated by prolonged suprapubic drainage. One patient had severe urethritis and one urinary tract infection. Four patients had a recurrent stricture after a mean of 12.4 months (range 3.7 to 17.5). Two patients underwent open repair using buccal mucosa and two refused repeated surgery.

CONCLUSIONS

In 4 patients, the operation was not successful. Because of the poor results, we discontinued the use of SIS for open urethral stricture repair.

Anastomotic Fibrous Ring as Cause of Stricture Recurrence After Bulbar Onlay Graft Urethroplasty

PURPOSE

We retrospectively reviewed patterns of failure after bulbar substitution urethroplasty. In particular we investigated the prevalence and location of anastomotic fibrous ring strictures occurring at the apical anastomoses between the graft and urethral plate after 3 types of onlay graft techniques.

MATERIALS AND METHODS

We reviewed the records of 107 patients who underwent bulbar urethroplasty between 1994 and 2004. Mean patient age was 44 years. Patients with lichen sclerosus, failed hypospadias repair or urethroplasty and panurethral strictures were excluded. A total of 45 patients underwent dorsal onlay skin graft urethroplasty, 50 underwent buccal mucosa onlay graft urethroplasty and 12 underwent augmented end-to-end urethroplasty. The clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 74 months (range 12 to 130).

RESULTS

Of 107 cases 85 (80%) were successful and 22 (20%) failed. Failure in 12 patients (11%) involved the whole grafted area and in 10 (9%) it involved the anastomotic site, which was distal and proximal in 5 each. Urethrography, urethral ultrasound and urethroscopy were fundamental for determining the difference between full-length and focal extension of re-stricture. Failures were treated with multistage urethroplasty in 12 cases, urethrotomy in 7 and 1-stage urethroplasty in 3. Of the patients 16 had a satisfactory final outcome and 6 underwent definitive perineal urinary diversion.

CONCLUSIONS

The prevalence and location of anastomotic ring strictures after bulbar urethroplasty were uniformly distributed in after 3 surgical techniques using skin or buccal mucosa. Further studies are necessary to clarify the etiology of these fibrous ring strictures.

Interim outcome of the single stage dorsal inlay skin graft for complex hypospadias reoperations

PURPOSE

Despite high success rates for primary hypospadias repair, some cases require multiple procedures for ultimate reconstruction. We report our experience with single stage dorsal inlay urethroplasty using skin grafts for complex reoperations.

MATERIALS AND METHODS

A total of 31 patients (mean age 13.8 years) with failed previous hypospadias surgery were included in the study. Indications included fistulas, strictures, diverticula and repair breakdown. The urethral plate had been removed or was severely scarred in all patients. A free penile or groin skin graft was sutured and quilted to the corpora cavernosa, guaranteeing sufficient blood supply. The neourethra was tubularized and covered with a tunica vaginalis or dartos flap, followed by glanuloplasty. Outcome analysis included urethrograms, urethral ultrasound and flow measurements.

RESULTS

Foreskin was used in 15 cases, penile skin in 12 and inguinal skin in 4. Average graft length was 3.92 cm. A total of 20 patients required glanuloplasty with a skin graft extended to the tip of the glans. After a mean followup of 30.71 months 5 patients underwent redo surgery, for a complication rate of 16.1%. Urethral stricture of the proximal anastomosis was the most frequent finding.

CONCLUSIONS

This single stage approach using dorsal skin grafts is a reliable method to create a substitute urethral plate for tubularization. Complication rates are equivalent to those of staged procedures. Foreskin should be used as a graft donor site to optimize the outcome if available. This approach represents a safe option for reoperations even if the urethral plate or midline penile skin is grossly scarred.

Experience with fibrin glue in bulbar urethral reconstruction using dorsal buccal mucosa graft

Buccal mucosa dorsal onlay graft urethroplasty represents a widespread method for bulbar urethral stricture repair. We describe a modified procedure with the use of fibrin glue applied on the receiving bed before graft location.

Comparison of donor site intraoral morbidity after mucosal graft harvesting for urethral reconstruction

OBJECTIVES

To compare postoperative intraoral morbidity after mucosal graft harvesting from the lower lip and inner cheek in men undergoing substitution urethroplasty.

METHODS

From 2000 to 2004, 40 patients underwent oral mucosal graft harvesting for urethral reconstruction. Of the 40 patients, 17 underwent harvest from the lower lip (group 1), 19 from the inner cheek (group 2), and 4 from both sites (group 3). We analyzed the postoperative differences in discomfort levels, neurosensory deficits, salivary flow, complications, and overall quality of life according to harvest site. Outcomes were assessed using analog scales and a questionnaire.

RESULTS

At longer term follow-up, the proportion of men with persistent postoperative discomfort, neurosensory deficits, and changes in salivary flow was greater in men whose grafts were harvested from the lower lip than in those whose grafts were harvested from the cheek. Contractures were noted in 1 (5.9%) of 17 and 5 (26.3%) of 19 men in groups 1 and 2, respectively. At the last follow-up visit, overall quality of life (measured by an analog scale of 0 [delighted] to 6 [terrible]) was not significantly different in patients with lower lip versus inner cheek harvest (1.35 versus 0.66, respectively, P = 0.079).

CONCLUSIONS

Persistent postoperative discomfort, neurosensory deficits, and salivary flow changes were more common in men whose grafts were harvested from the lower lip. However, the overall quality of life in this group was not significantly different compared with men whose grafts were harvested from the inner cheek. From a morbidity standpoint, the inner cheek appears to be the preferable site of graft harvest.

Long-term outcome of ventral buccal mucosa onlay graft urethroplasty for urethral stricture repair

OBJECTIVES

To evaluate our patients who were treated with ventral buccal mucosa onlay grafts for open urethral stricture repair with a follow-up exceeding 5 years. Buccal mucosa onlay is widely used for urethral reconstruction; however, the long-term outcome of these patients remains unclear.

METHODS

During the past 10 years, 67 patients underwent ventral buccal mucosa onlay graft surgery for urethral stricture repair. Of these, 32 were followed up for longer than 5 years (mean 6.9 years) for the occurrence and timing of any postoperative complications. All patients had undergone prior internal urethrotomy (mean 2.9 procedures), and the average length of the stricture was 4.3 cm (range 3 to 17).

RESULTS

The overall complication rate was 25% (8 of 32). We observed one fistula, one graft infection/necrosis, two lower lip scars with transient impairment of lip motility, and four recurrent strictures (at the proximal anastomosis), all of which were treated successfully with internal urethrotomy. All but one recurrent stricture occurred during the first 12 postoperative months.

CONCLUSIONS

Ventral buccal mucosa onlay grafting for urethral stricture repair provides stable long-term results with complications occurring primarily during the first 12 postoperative months.

Komplizierte Harnröhrenrekonstruktionen bei Erwachsenen und Kindern

The urethral reconstruction is a challenge in the adult, but even more in infant and young male patients. Good knowledge of the anatomy of the penis (blood supply and the course of the nerve fibers) with the availability of microsurgery suturing and instruments improved the outcome significantly. The growing knowledge opened the possibility to reconstruct complicate strictures with grafts. The buccal mucosa flap is one of those improvements, which made a tremendous impact to have a successful outcome. Recently we looked into the outcome of urethral reconstruction of long urethral strictures by using a buccal mucosa only flap. We used a modified technique for hypospadias repair to reconstruct coronar or subcoronar defects by meatal mobilization (MEMO). In cases with a long urethral stricture the success rate was over 90% with a mean follow up of 16 months. In all children the outcome with the MEMO-technique was successful without any major complication with a mean follow-up of 12.5 months.

Dorsal onlay graft urethroplasty using penile skin or buccal mucosa for repair of bulbar urethral stricture: results of a prospective single center study

OBJECTIVE

To compare the outcomes of dorsal onlay graft urethroplasty using penile skin (PS) or buccal mucosa (BM) free grafts in the repair of adult bulbourethral strictures.

METHODS

From January 1998 to March 2003, 30 patients with bulbar urethral strictures underwent urethral reconstruction with PS (17) or with BM free graft (13). Follow-up was done at 6, 12 and 18 months postoperatively, and every year subsequently. Success was defined as normalization of IPSS and a stable Q(max) value >20 ml/s. Any further instrumentation for stricture recurrence was considered a failure.

RESULTS

Mean follow-up was 51 months (20-74). The overall success rate was 80% (85% in the BM and 76% in the PS group). Improvement of uroflowmetry, IPSS and QoL did not show a significant difference between the two groups. A significant improvement of the orgasmic function domain of the IIEF was found in patients treated with a PS graft. Post-operative complications were lip hypoesthesia (30%), retraction of the ventral skin of the penis (7%), post-voiding dribbling (8% with BM graft, and 7%, with PS graft). Six patients, 2 with BM (15%) and 4 with PS graft patch (24%) required further treatment due to stricture recurrence.

CONCLUSION

Results of PS or BM graft are comparable at 18 month follow-up, although orgasmic function is significantly improved in patients receiving a PS graft. Nevertheless, with extended follow-up, the use of PS seems to be associated with a higher failure rate.

Long-term followup of buccal mucosa onlay graft for hypospadias repair: analysis of complications

PURPOSE

We review the long-term results of buccal mucosa onlay grafting for urethral reconstruction in hypospadias surgery in patients with followup of at least 5 years.

MATERIALS AND METHODS

We retrospectively evaluated 132 patients who underwent buccal mucosa onlay graft for hypospadias repair, including 34 who underwent "salvage" grafting, during a 10-year period at our institution. In 49 cases with available followup longer than 5 years (average 6.2) complications were analyzed in detail.

RESULTS

The overall complication rate was 24% (12 of 49 patients), with all but 3 complications occurring during the first postoperative year (3 fistulas, 1 stricture, 1 meatal stenosis, 2 graft contractures, 2 scars at oral harvesting site). The remaining 3 complications manifested during postoperative years 2 and 3, and encompassed 2 anastomotic strictures at the proximal anastomosis and 1 meatal stenosis.

CONCLUSIONS

Buccal mucosa onlay grafts for urethral reconstruction in hypospadias repair seem to provide stable long-term results, with complications occurring primarily during the first 12 months postoperatively.

Interim outcomes of dorsal skin graft bulbar urethroplasty

PURPOSE

We update our interim results of bulbar urethroplasty using a skin graft placed on the dorsal urethral surface.

MATERIALS AND METHODS

A total of 45 patients with an average age of 45 years underwent dorsal onlay skin graft urethroplasty between January 1994 and December 2000. Of the patients 23 had undergone an average of 2.6 prior endoscopic procedures (range 1 to 14). Preoperative evaluation include clinical history, physical examination, retrograde and voiding urethrography, and ultrasonography. In all patients the bulbar urethra was opened along its dorsal surface, the graft was sutured, splayed and quilted to the corpora cavernosa, and the urethra was rotated to cover the graft. In all patients was used penile skin as substitution material. Mean graft length was 4.7 cm (range 2.5 to 11). Three weeks after surgery voiding cystourethrography was performed.

RESULTS

Average followup was 71 months (range 41 to 110). Clinical outcome was considered a failure when postoperative instrumentation was needed, including dilation. Of 45 cases 33 (73%) were classified as successful and 12 (27%) were failures. The 12 failures were treated with internal urethrotomy (1), end-to-end-anastomosis (1), skin graft urethroplasty (2) and 2-stage urethroplasty (6). Six of the 12 initial failures had a satisfactory final outcome. The remaining 6 patients refused further surgical procedures and received a definitive perineal urethrostomy.

CONCLUSIONS

Penile skin grafts used as a dorsal onlay for bulbar urethral reconstruction in a homogeneous series of patients showed a tendency to deteriorate with time. Longer followup is required to compare penile skin with buccal mucosa as substitute materials for bulbar urethral reconstruction.

Reconstrução uretral com retalho autógeno de mucosa bucal após uretrostomia, em cães

OBJETIVO: Verificar se fragmentos de mucosa bucal autógena poderiam ser adequados para reconstrução uretral na presença de tecido fibroso, e se tal procedimento poderia determinar a formação de fístulas e ou saculações nos sítios implantares. MÉTODOS: Sete cães adultos foram submetidos à uretrostomia pré-escrotal. Após 40 dias, a uretrostomia foi corrigida por meio da implantação de fragmentos de mucosa bucal na parede ventral da uretra. Os animais foram observados durante 40 dias, quando então, foram submetidos a exames radiográficos e sacrificados para estudo histológico. RESULTADOS: Todos os animais apresentaram cistite e fístulas uretro-cutâneas de duração média de vinte dias foram observadas em seis deles. O aspecto radiográfico aos 40 dias após a reconstrução uretral mostrou: continuidade luminal em sete animais e presença de saculações na parede ventral da uretra em seis, sem interferência na qualidade do jato urinário. As características histológicas indicam integração completa da mucosa bucal ao sítio receptor. CONCLUSÃO: O implante em retalho ventral, com fragmentos de mucosa bucal autógena é adequado para correção de defeito uretral produzido por uretrostomia no cão embora possa ocorrer a formação de saculações no sítio do selamento.

Ventral onlay buccal mucosal grafts for anterior urethral strictures: long-term followup

PURPOSE

We present our long-term experience with buccal mucosal grafts, placed ventrally, for the treatment of anterior urethral strictures.

MATERIALS AND METHODS

A total of 23 patients with anterior urethral strictures underwent urethral reconstruction using buccal mucosa as a ventral onlay graft, with 18 grafts placed in the bulbar and 5 in the penile urethra. All operations were performed in 1 stage by a single surgeon (NAA). Mean graft length was 4.9 cm (range 3 to 12). International Prostate Symptom Score and uroflowmetry were obtained preoperatively, at 3, 6 and 12 months postoperatively, and annually thereafter. Urethral imaging was obtained preoperatively, at catheter removal and selectively thereafter.

RESULTS

Patients were followed for a mean of 50 months (range 17 to 94). Etiology of the strictures was instrumentation (in 9), idiopathic (in 9), prior hypospadias repair (in 2), urethritis (in 2) and trauma (in 1). Of the 23 patients 21 (91%) were previously treated for urethral stricture with a total of 59 procedures (mean 2.8 procedures per patient). Success, defined as normal voiding without any need for subsequent urethral manipulation, was achieved in 20 of 23 patients (87%). A distal anastomotic stricture developed in the remaining 3 patients, each managed with 1 internal urethrotomy. One of these patients continues to require monthly self-dilations. There were no fistulas or clinically perceptible graft sacculations.

CONCLUSIONS

With long-term followup our series confirms the durability of ventrally placed buccal mucosal grafts for the treatment of anterior urethral strictures. This proven procedure results in a high success rate with few complications.

Anterior urethral strictures

The surgical treatment of adult anterior urethral strictures has developed continuously. Recently considerable changes have been introduced, involving the cause of the urethral disease and surgical techniques. The criteria for selecting the reconstructive surgical technique are presented according to the cause and a new classification of urethral strictures. The main surgical procedures are presented and fully illustrated, with an updated and comprehensive review of recent publications.

Uretroplastia de substituição com segmentos tubulares autólogos de mucosa bucal em cães

OBJETIVO: Avaliar a reconstrução de defeitos experimentais na uretra do cão com a implantação de segmentos tubulares de mucosa bucal autóloga. MÉTODOS: Procedeu-se à ressecção de cerca de 2 cm da uretra peniana de 20 cães. O defeito produzido foi corrigido por meio da anastomose de fragmento tubular de mucosa bucal autóloga, seccionado do lábio inferior. RESULTADOS: Entre os animais operados, 14 (70%) apresentaram jato urinário normal e seis (30%) evidenciaram estenose confirmada por meio de exame radiológico realizado aos 60 dias do pós-operatório. Durante a necrópsia verificou-se a integridade dos implantes no sulco uretral, associado a infiltrado inflamatório de neutrófilos, linfócitos piócitos e histiócitos. As análises histológicas revelaram que os fragmentos implantados estavam recobertos pelo epitélio uretral. CONCLUSÃO: A implantação de segmentos autólogos de mucosa bucal é adequada para a reconstrução de defeitos uretrais iatrogênicos no cão, embora possa resultar em estenose pós-operatória.

Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction

PURPOSE

We investigate whether the short-term success rate (greater than 90%) of buccal mucosa free grafts in the bulbar urethra is sustained in the long term.

MATERIALS AND METHODS

In 60 patients a ventrally placed buccal mucosa graft was used for repair of bulbar urethral strictures. Of these patients 49 had undergone previous attempt at repair (urethroplasty in 4, internal urethrotomy in 45). Mean graft length was 4.8 cm. In 9 patients a distal penile fasciocutaneous flap was also used for repair of concomitant penile urethral stricture. In 8 of the 9 patients the buccal mucosa graft was combined with end-to-end urethroplasty and 2 buccal mucosa grafts were used in tandem in 1. Followup was at least 1 year in all cases (mean 47 months, range 12 to 107). Failure was defined as an obstructive voiding pattern with radiographic or cystoscopic evidence of recurrent stricture.

RESULTS

Bulbar stricture repair was successful in 54 patients (90%) and 4 of the remaining 6 responded to 1 internal urethrotomy for a long-term success rate of 97%. Preoperative clinical characteristics were not significantly different between those who experienced success or failure.

CONCLUSIONS

Long-term outcome analysis of ventrally placed buccal mucosa onlay grafts for bulbar urethral strictures demonstrates a durable success rate of 90%. This rate can be improved (97%) with the judicious use of internal urethrotomy.

Ventral onlay urethroplasty using buccal mucosa for complex stricture repair

OBJECTIVES

To report the short to medium-term results of one-stage buccal mucosa ventral onlay in the treatment of recurrent urethral stricture disease.

METHODS

Between April 1997 and July 2001, buccal mucosa was used as a ventral onlay graft in 38 patients with recurrent strictures of the bulbar (n = 30) and proximal penile urethra (n = 8). All patients had undergone at least 1 urethrotomy (range 1 to 10; mean 2.9) before reconstruction. Prospective follow-up included a simple questionnaire on patient satisfaction, uroflowmetry, and ultrasound estimation of postvoid residual urine volume and, in the case of recurrence, retrograde urethrography and cystoscopy.

RESULTS

The primary success rate at a mean follow-up of 22.8 months (range 8.7 to 40.7) was 80%. Stricture recurred in 7 patients, mostly within 12 months. A distinct residual irregularity at the former stricture site in the initial postoperative urethrogram was predictive of failed reconstruction. A second procedure was performed in 4 patients (1 urethrotomy and 3 re-buccal mucosa onlay grafts) with good results. Patient satisfaction was high in most instances. Three patients refused reoperation, preferring regular intermittent dilation.

CONCLUSIONS

When end-to-end anastomosis is impossible, onlay urethroplasty using buccal mucosa is a rather simple alternative with encouraging short to medium-term results in the proximal segments of the male urethra.

Bulbar urethroplasty using the dorsal approach: current techniques

INTRODUCTION

The use of flaps or grafts is mandatory in patients with longer and complex strictures. In 1995-96 we described a new dorsal onlay graft urethroplasty. Over time, our original technique was better defined and changed. Now this procedure (also named Barbagli technique) has been greeted with a fair amount of enthusiasm in Europe and in the United States.

SURGICAL TECHNIQUE

The patient is placed in normal lithotomy position, and a midline perineo-scrotal incision is made. The bulbar urethra is then free from the bulbo-cavernous muscles, and is dissected from the corpora cavernosa. The urethra is completely mobilized from the corpora cavernosa, it is rotated 180 degrees, and is incised along its dorsal surface. The graft (preputial skin or buccal mucosa) or the flap is fixed and quilted to the tunica albuginea of the corporal bodies. The right mucosal margin of the opened urethra is sutured to the right side of the patch-graft. The urethra is rotated back into its original position. The left urethral margin is sutured to the left side of the patch graft and to the corporal bodies, and the grafted area is entirely covered by the urethral plate. The bulbo-cavernous muscles are approximated over the grafted area. A 16F silicone Foley catheter is left in place.

COMMENTS

Dorsal onlay graft urethroplasty is a versatile procedure that may be combined with various substitute materials like preputial skin, buccal mucosa grafts or pedicled flaps.

One-stage circumferential buccal mucosa graft urethroplasty for bulbous stricture repair

A one-stage onlay urethroplasty, using a buccal mucosa graft, is presented for patients with bulbous strictures in whom the urethral mucosa is seriously involved in the disease. Of 40 patients who underwent a dorsal buccal mucosa graft urethroplasty for bulbous urethral strictures, 5 required complete removal of the urethral mucosa and its replacement by a buccal mucosa graft. All these patients had undergone previous urethrotomy with a false passage inside the bulbous urethra and had a suprapubic tube in place. The goal of removal and replacement of the urethral mucosa in each case was to create a new, wide urethral mucosal bed to promote successful one-stage reconstruction. All patients voided spontaneously without problems after removal of the catheter. After 4 months, the mean peak flow was 21 mL/s. After 6 months, urethroscopy did not show any stricture recurrence. None of the patients required instrumentation or dilation. In patients with bulbous urethral strictures and false passage into the mucosa and spongiosum tissues, the complete removal and replacement of the urethral mucosa using a circumferential buccal mucosa graft promotes successful one-stage urethral reconstruction.

Avaliação da triangulação da anastomose término-terminal de fragmento de mucosa bucal na reconstrução uretral: estudo experimental no cão

O uso da mucosa bucal para tratar a estenose uretral tem sido considerado um excelente método alternativo para substituir o tecido uretral. OBJETIVO: Investigar os resultados da realização da triangulação da anastomose término-terminal de fragmento de mucosa bucal na reconstrução uretral. MÉTODOS: Foram utilizados 12 cães entre 13 e 17 Kg, sem raça definida, aparentemente sadios. Após anestesia, introduziu-se sonda na uretra dos animais que foi mantida durante todo ato operatório. Inicialmente procedeu-se a ressecção de um fragmento de mucosa bucal do lábio superior e imerso em solução salina com cloranfenicol aquoso. A seguir procedeu-se a exposição da uretra peniana e ressecou-se um segmento de dois centrímetros. Foi realizada a triangulação da anastomose término-terminal do fragmento de mucosa bucal na reconstrução uretral. RESULTADOS: Após 60 dias observou-se a ocorrência de estenose em 25% dos animais. Foram observadas fístulas uretro-cutâneas e extravasamento de contraste no local das anastomoses. CONCLUSÃO: A triangulação da anastomose término-terminal de fragmento de mucosa bucal na reconstrução uretral não evita a ocorrência de estenose.

Which urethroplasty for which results?

PURPOSE OF REVIEW

Urethral surgery is rapidly changing because of developments in techniques. The aim of this paper is to provide an update and a review of the most significant surgical options and their outcomes in the treatment of urethral strictures.

RECENT FINDINGS

Indications and results of anastomotic repair, pedicled flap, free graft and complex urethral reconstruction are reported. New trends such as dorsal urethroplasty and the use of buccal mucosa are reviewed.

SUMMARY

Most urethral strictures can be managed successfully by urethral surgery. A wide spectrum of effective procedures is available. To obtain optimal results, adequate knowledge and experience of the most common techniques are required.

Dorsal onlay techniques for urethroplasty

Dorsal onlay graft urethroplasty is a versatile procedure which may be combined with various substitute materials such as preputial skin, buccal mucosa grafts or pedicled flaps. Others substitute materials such as human urethral mucosa from corpses or collagen matrix will be possible in future. The long-term results of a wide series of patients showed a final success rate from 92% to 97%. Any kind of substitution urethroplasty deteriorate over time, and in our series of patients with an extended follow-up from 21.5 to 43 months the success rate of dorsal onlay graft urethroplasty decreased from 92% to 85%. With regard to substitute material concerns (buccal mucosa versus preputial skin) a long-term follow-up is mandatory to establish if buccal mucosa is superior to foreskin as urethral substitute material. At present, the authors currently use both according to patient preference, status of the genital tissues or strictures characteristics.

Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction

PURPOSE

Buccal mucosa has been advocated as an ideal graft material for urethral reconstruction. We report our multicenter experience with buccal mucosa ventral onlay urethroplasty for complex bulbar urethral reconstruction in adults.

MATERIALS AND METHODS

A retrospective analysis of patients who had undergone buccal onlay urethroplasty at 4 military medical treatment facilities participating in the Uniformed Services Urology Research Group was performed. The database generated included demographic data, genitourinary history, preoperative symptoms (American Urological Association symptom score), preoperative urinary flow rate, stricture length and operative statistics. Postoperative followup data included symptom score, flow rate, retrograde urethrogram results, and complications.

RESULTS

A total of 53 patients (average age 32 years, range 17 to 64) underwent buccal mucosa graft urethroplasty between January, 1996 and March, 1998 for refractory strictures. Sixteen patients had undergone an average of 2.2 prior endoscopic procedures (range 1 to 7). Average stricture length was 3.6 plus or minus standard deviation 1.8 cm. (range 2 to 7.5) as measured on preoperative retrograde urethrogram. Followup averaged 25 months (range 11 to 40 months). Average symptom scores decreased from 21.2 (range 14 to 33) preoperatively to 5.4 (range 3 to 8) postoperatively (p <0.001). Average peak urinary flow rates increased from 7.9 preoperatively to 30.1 ml. per second postoperatively (p <0.001). Postoperative retrograde urethrograms were available for 34 patients and were normal in 24. The overall complication rate was 5.4%. Three patients required endoscopic incisions. One patient has a recurrent narrowing and treatment is considered a failure. There were 4 sacculations (7.5%) and 6 narrowings, 3 of which required further treatment. Of the patients 50 required no additional procedures (94.3%).

CONCLUSIONS

Buccal mucosa grafts used as a ventral onlay for bulbar urethral reconstruction yield reproducibly excellent results with minimal morbidity and low complication rates. Longer followup will be required to confirm the durability of our results.

New 2-stage buccal mucosal graft urethroplasty

PURPOSE

Previously buccal mucosal grafts used for repairing adult bulbourethral stricture with the 1-stage dorsal technique has provided a satisfactory outcome in our experience. We present the wider use of buccal mucosal grafts for 2-stage urethroplasty.

MATERIALS AND METHODS

A total of 24 men 25 to 60 years old (median age 45) with a complex bulbar stricture underwent 2-stage urethroplasty using a buccal mucosal graft to repair the perineostomy. The primary etiology of stricture was traumatic in 4 cases, inflammatory in 16 and unknown in 4. The 2 x 6 cm. graft was harvested from the inner cheek and sutured to the left margin of the urethral mucosal plate with running 6-zero polyglactin suture. Patients were discharged from the hospital within 3 days with a 14Fr silicone urethral catheter in place. Radiological studies and urethroscopy were done 1 year after closure.

RESULTS

A final successful outcome with no recurrent stricture was achieved in 23 of 24 men (92.8%) at a median followup of 18 months (range 13 to 32). In 1 case a urethrocutaneous fistula at the initial radiological assessment closed spontaneously after 14 days of catheterization. No urethral diverticula developed. The mean postoperative peak flow rate is 22 ml. per second (range 18 to 25).

CONCLUSIONS

Our new 2-stage buccal mucosal graft urethroplasty may be an excellent technique for complex bulbar urethral stricture disease. Our suggestions may increase usefulness of the 2-stage technique for repairing complex strictures due to the avoidance of classic complications.

LONG-TERM OUTCOME OF URETHROPLASTY AFTER FAILED URETHROTOMY VERSUS PRIMARY REPAIR

PURPOSE

A urethral stricture recurring after repeat urethrotomy challenges even a skilled urologist. To address the question of whether to repeat urethrotomy or perform open reconstructive surgery, we retrospectively review a series of 93 patients comparing those who underwent primary repair versus those who had undergone urethrotomy and underwent secondary treatment.

MATERIALS AND METHODS

From 1975 to 1998, 93 males between age 13 and 78 years (mean 39) underwent surgical treatment for bulbar urethral stricture. In 46 (49%) of the patients urethroplasty was performed as primary repair, and in 47 (51%) after previously failed urethrotomy. The strictures were localized in the bulbous urethra without involvement of penile or membranous tracts. The etiology was ischemic in 37 patients, traumatic in 23, unknown in 17 and inflammatory in 16. To simplify evaluation of the results, the clinical outcome was considered either a success or a failure at the time any postoperative procedure was needed, including dilation.

RESULTS

In our 93 patients primary urethroplasty had a final success rate of 85%, and after failed urethrotomy 87%. Previously failed urethrotomy did not influence the long-term outcome of urethroplasty. The long-term results of different urethroplasty techniques had a final success rate ranging from 77% to 96%.

CONCLUSIONS

We conclude that failed urethrotomy does not condition the long-term result of surgical repair. With extended followup, the success rate of urethroplasty decreases with time but it is in fact still higher than that of urethrotomy.

Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures

PURPOSE

We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures.

MATERIALS AND METHODS

Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra.

RESULTS

At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group.

CONCLUSIONS

Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.