Oral Mucosa Harvest: An Overview of Anatomic and Biologic Considerations

Urethroplasty Outcomes for Pars Fixa Urethral Strictures Following Gender-affirming Phalloplasty and Metoidioplasty: A Retrospective Study

OBJECTIVE

To evaluate outcomes of three urethroplasty techniques for pars fixa (PF) urethral strictures and provide a treatment algorithm based on stricture characteristics. The PF is an essential anatomic region of the neourethra created in gender-affirming phalloplasty and metoidioplasty. Urethral strictures in this region present a reparative challenge given its unique anatomy and vascularization.

METHODS

A total of 41 urethroplasties performed on 41 patients between March 2018 and June 2021 were reviewed at two surgical centers. A Heineke-Mikulicz (HM) repair was done for strictures under 20 mm when the proximal and distal urethral segments were mobile and supported a tension-free closure. Substitution urethroplasty with ventral onlay buccal mucosal graft was utilized for strictures under 40 mm not suitable for HM repair. Complex or long (≥40 mm) strictures were treated by two-stage Johansen urethroplasty. Success of each surgical approach was defined by a minimum of 12-month follow-up without the need for a repeat intervention.

RESULTS

Mean follow-up was 30.2 months (range: 12.4-52.0 months). Mean stricture length was 16.9 mm (range: 2-55 mm). Most strictures (46%) were located at the distal PF. HM urethroplasty had a success rate of 44% (n = 16). Substitution urethroplasty had a success rate of 92% (n = 13). Two-stage Johansen urethroplasty had a success rate of 75% (n = 12).

CONCLUSION

The success rates of PF urethral stricture repair ranged from 44% to 92% depending on the surgical approach, and the best reparative procedure depends on stricture length, severity, and local tissue mobility.

A New 3-Stage Approach for Reoperative Hypospadias

BACKGROUND

Most hypospadias patients undergo 1 surgical procedure and go on to live normal lives. However, there is a small subset of patients who have remaining functional complications after their repair. Patients presenting with diffuse scarring of the urethral plate and a shortage of penile skin for closure are referred to as "hypospadias cripples." We present our experience using tissue expanders in the treatment of reoperative hypospadias with skin deficiency.

METHODS

We retrospectively reviewed hospital records from 2009 to 2019. Five hypospadias cripple patients were encountered. A multidisciplinary team involving plastic surgery and pediatric urology collaborated a 3-stage reconstructive plan:Stage 1-Scar excision and buccal mucosal graft harvestStage 2-Dorsal tissue expander placementStage 3-Tissue expander explantation, creation of neourethra, and skin closure.

RESULTS

Successful skin closures were achieved in all patients. There were no cases of expander explanation. Average time between tissue expander placement and final reconstruction ranged from 3 to 4 months. Complications included 2 cases of penile cellulitis, 1 with an associated abscess, and 2 limited urethrocutaneous fistulas, which were addressed with an additional operative procedure.

CONCLUSIONS

The 3-stage approach is advantageous in treating hypospadias cripple patients. This population can benefit greatly from tissue expander placement after buccal result with an acceptable complication rate. Using a multidisciplinary approach is beneficial in treating these complex patients.

Histological Comparison of Buccal and Lingual Mucosa Grafts for Urethroplasty: Do They Share Tissue Structures and Vascular Supply?

Comparable outcomes were published using a buccal mucosa graft (BMG) from the cheek and a lingual mucosa graft (LMG) from the sublingual area, for urethral augmentation or substitution. To date, no histological comparison between both grafts has been conducted. We histologically assessed BMG and LMG harvested during urethral surgeries, aiming to compare graft properties and vascular support. We conducted a prospective single cohort study, including oral mucosa urethroplasty patients. During surgery, graft dimensions and donor sites were collected, and a 0.5 × 0.5 cm sample was obtained from the prepared graft. Formalin-fixed paraffin-embedded samples were sliced at 4 micrometres (µm) and hematoxylin-eosin stained. Using a telepathology tool, all slides were digitalized and measured from 10× to 40× magnification. In each graft, global and individual layers thicknesses were assessed, including vascular density and area. Descriptive and comparative (parametrical and non-parametrical) statistical analysis occurred. We collected 57 grafts during 33 urethroplasties, with 30 BMG and 22 LMG, finally, included. The mean age was 56.6 (SD 15.2) years, and the mean graft length was 5.8 (SD 1.7) cm and the width was 1.7 (SD 0.4) cm. The median graft thickness was 1598.9 (IQR 1200–2100) µm, the mean epithelium layer was 510.2 (SD 223.7) µm, the median submucosa was 654 (IQR 378–943) µm. the median muscular was 477.6 (IQR 286–772) µm, the median vascular area was 5% (IQR 5–10), and the median adipose tissue area was 5% (IQR 0–20). LMG were significantly longer and narrower than BMG. Total graft thickness was similar between LMG and BMG, but the epithelium and submucosa layers were significantly thinner in LMG. The muscular layer was significantly thicker in LMG. Vascular density and vascular areas were not significantly different between both types of grafts. LMG showed significantly less adipose tissue compared with BMG. Our findings show LMG and BMG for urethroplasty surgeries share the same thickness and blood supply, despite having significantly different graft sizes as well as mucosal and submucosal layers thickness.

Robotic-assisted Lingual Mucosal Graft Ureteroplasty for the Repair of Complex Ureteral Strictures: Technique Description and the Medium-term Outcome

BACKGROUND

Robot-assisted autologous graft ureteroplasty provides another treatment option for complex ureteral strictures, circumventing ileal ureter or renal autotransplantation.

OBJECTIVE

To report the medium-term outcome of robotic ureteroplasty with a lingual mucosal graft (RU-LMG) for managing complex ureteral strictures.

DESIGN, SETTING, AND PARTICIPANTS

Between June 2019 and September 2020, 12 patients underwent RU-LMG. The perioperative variables were prospectively collected, and the outcomes were assessed.

SURGICAL PROCEDURE

After ureteral stricture dissection, the narrow segment was cut longitudinally, and a lingual mucosal graft (LMG) of the required length was harvested, followed by double-J stent placement and LMG ventral onlay anastomosis. If the diseased ureter required transection, posteriorly augmented ureteral anastomosis could be performed before LMG harvest. Finally, the anastomotic area was wrapped by the omental flap.

MEASUREMENTS

A descriptive statistical analysis was performed. The criteria for complete success included the absence of both clinical symptoms and obstruction on radiography.

RESULTS AND LIMITATIONS

Seven patients (58%) had a history of failed ureteral reconstruction. The mean (range) stricture length was 4.7 (3-6.5) cm, LMG length was 4.4 (3-7) cm, LMG width was 1.5 (1-2) cm, operative duration was 197.1 (130-346) min, estimated blood loss was 49.2 (10-200) ml, and the duration of postoperative hospitalization was 6 (4-14) d. No open conversions and intraoperative complications occurred. The median follow-up time was 15 mo (range: 13-27 mo). The overall success rate was 92% (11/12).

CONCLUSIONS

These medium-term follow-up results demonstrate that RU-LMG is a safe and feasible technique for repairing ureteral strictures.

PATIENT SUMMARY

Our study proves that robotic ureteroplasty with a lingual mucosal graft is a safe and feasible technique for ureteral reconstruction that can serve as another choice for managing long, complex ureteral strictures.

The Expanding Use of Buccal Mucosal Grafts in Urologic Surgery

The advent and success of buccal mucosal grafts as a substitution material in the urinary tract has changed the landscape of reconstructive urology. Due to its ease to harvest, low morbidity, and advantageous properties, there has been a growing number of applications for buccal mucosal grafts in upper and lower urinary tract reconstruction as well as genital reconstruction. In this article, we review the historical application and the evolution of buccal mucosal grafts and provide an up-to-date review on its utilization in urologic procedures.

Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which Technique Is Best? A Systematic Review

CONTEXT

Four techniques for graft placement in one-stage bulbar urethroplasty have been reported: dorsal onlay (DO), ventral onlay (VO), dorsolateral onlay (DLO), and dorsal inlay (DI). There is currently no systematic review in the literature comparing these techniques.

OBJECTIVE

To assess if stricture recurrence and secondary outcomes vary between the four techniques and to assess if one technique is superior to any other.

EVIDENCE ACQUISITION

The EMBASE, MEDLINE, and Cochrane Systematic Reviews-Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED) databases and ClinicalTrials.gov were searched for publications in English from 1996 onwards. Randomised controlled trials (RCTs), nonrandomised comparative studies (NRCSs), observational studies (cohort, case-control/comparative, single-arm), and case series with ≥20 adult male participants were included.

EVIDENCE SYNTHESIS

A total of 41 studies were included involving 3683 patients from one RCT, four NRCSs, and 36 case series. Owing to the overall low quality of the evidence, a narrative synthesis was performed.

CONCLUSIONS

No single technique appears to be superior to another for bulbar free graft urethroplasty. Both DO and VO are suitable for bulbar augmentation urethroplasty, with a ≤20% recurrence rate over medium-term follow-up. No recommendations can be made regarding DI or DLO techniques owing to the paucity of evidence. Secondary outcomes including sexual function, and complications are infrequently reported. Recurrence rates deteriorate in the long term for both DO and VO procedures.

PATIENT SUMMARY

We reviewed the evidence for four different skin-graft techniques used to repair narrowing of a section of the urethra (bulbar urethra, under the scrotum and perineum) in men. Two of the techniques seem to give consistent results, with recurrence rates lower than 20%. Recurrence rates increase over time, so patients should continue to monitor their symptoms. There is poorer reporting of other outcomes such as sexual function, urinary symptoms, and complications, and it is possible that these occur more frequently than the current data suggest.

Glans Preservation in Surgical Treatment of Distal Urethral Strictures With Dorsal Buccal Mucosa Graft Onlay by Subcoronal Approach

OBJECTIVE

To describe dorsal onlay buccal mucosa graft urethroplasty technique by subcoronal approach and glans preservation in distal penile urethral strictures with fossa navicularis involvement and to report safety, effectiveness, and cosmetic outcomes.

METHODS

Retrospective review of a prospective database of patients treated at Hospital Italiano de Buenos Aires between January 2011 and December 2019. Main surgical steps: ventral subcoronal incision, dorsal dissection of glandelar urethra until piercing the tip of the glans, dorsal urethrotomy, and graft transposition. Low urinary tract symptoms, uroflowmetry, and urinalysis were assessed at follow-up. Simplified International Index Erectile Function and Hypospadias Objective Scoring Evaluation were applied 1 year after surgery.

RESULTS

Sixteen patients with a median age of 56.5 years (IQR 35.7-66.7) were included. Median stricture length was 5.5 cm (IQR 4-8.7). In 3 patients, Clavien-Dindo grade I-II complications were reported. At 1 year, median peak flow was 18 mL/seg (IQR 12.7-27.4) and median mean flow 7.8 mL/seg (IQR 6.1-9.9). At 41.5 months follow-up (IQR 13.2-74), all patients were stricture free and had no changes in erectile function. Hypospadias Objective Scoring Evaluation score ≥14 points was achieved by 14 patients (87.5%).

CONCLUSION

For treatment of distal penile urethral strictures with fossa navicularis involvement, dorsal onlay buccal mucosa graft by subcoronal approach and glans preservation is a feasible technique with excellent functional outcomes, minimal complications, and substantial cosmetic results.

Overview on metoidioplasty: variants of the technique

Number of gender dysphoric people increased over the last few decades with positive social acceptance of transpopulation. Genital gender affirming surgeries are of utmost importance in order to adjust body to the mind of these individuals. Creation of the phallus is usually the last step in transmen transition, which remains demanding and challenging for surgeons, with different options for phalloplasty available. The ideal phallus is esthetically appealing, with preserved tactile and erogenous sensation, enables standing micturition and sexual function with minimal donor-site morbidity. Metoidioplasty, as a variant of phalloplasty, uses the hormonally hypertrophied clitoris to create the neophallus. Metoidioplasty can be considered as a method of choice for thin-built individuals looking for male genitalia with preserved erogeneity, in one-stage genital gender affirming surgery. It can be combined together with removal of reproductive organs and vaginectomy. Preoperative consultation with patients and postoperative follow-up as well as multidisciplinary approach are essential for successful treatment.This literature review aims to assess and discuss different metoidioplasty approaches with a special reference to authors' current metoidioplasty technique.

Augmentation vaginoplasty with buccal mucosa for the surgical revision of postreconstructive vaginal stenosis: a case series

BACKGROUND

Vaginal stenosis is a common consequence of vaginal reconstruction in childhood. Significant scarring can make dilation ineffective, and there maybe a paucity of skin to create perineal skin flaps. Numerous vaginoplasty techniques exist, including perineal skin flaps for distal stenosis and intestinal vaginoplasty requiring laparotomy and bowel anastomosis. Buccal mucosa graft is widely used in urethroplasty and has been reported in neovaginal construction. It is easily accessible with minimal graft site morbidity and provides a close functional replica to vaginal mucosa.

AIM

The aim was to describe the use of buccal mucosa grafts for the surgical revision of postreconstructive vaginal stenosis.

METHOD

The study setting was a tertiary centre for congenital gynaecological anomalies. Buccal mucosa grafting was provided to women with vaginal stenosis unsuitable for perineal skin flaps and in whom intestinal vaginoplasty was the next option. Four cases have been performed, and the medical notes were reviewed for clinical data.

RESULTS

Mean age at buccal mucosa vaginoplasty was 21 years (range 18-26 years). Two patients had a cloacal anomaly, one had mosaic Turner syndrome and one had postradiation vaginal stenosis. All four had undergone previous vaginal reconstruction. In all cases, there was a tight band of vaginal stenosis either too proximal or with insufficient perineal tissue to allow a perineal flap vaginoplasty. There were no immediate complications. Mean clinic follow-up was 16 months (3 months-4 years). Two patients were able to have penetrative sexual intercourse, and two were using vaginal dilators successfully. Patients have an email contact for the team nurse specialist and therefore are able to contact before clinical review if they develop concerns.

DISCUSSION

The use of buccal mucosal grafts for vaginoplasty is increasingly reported. This is the first detailed case series describing its use for augmentation vaginoplasty with postreconstructive/stenosis.

CONCLUSIONS

All patients had a successful outcome with a normal capacity vagina, and two were able to have penetrative intercourse. This suggests that buccal mucosal graft vaginoplasty is a safe and effective alternative for women with previous vaginal reconstruction requiring surgery for vaginal stenosis.

What Is the Best Way to Prepare A Buccal Mucosa Graft for Urethroplasty? A Histology-Based Preliminary Report

PURPOSE

To evaluate the histological characteristics of buccal mucosa samples prepared using different dissection techniques.

METHODS

The buccal mucosae harvested from 9 men submitted to a substitution urethroplasty were used in this study. Biopsy specimens of buccal mucosae were grouped according to the macroscopic appearance after dissection: Group 1 - yellowish appearance (minimal dissection), Group 2 - whitish appearance (more aggressive dissection), and Group 3 - translucent appearance (ultra-aggressive dissection). The biopsy specimens were evaluated using histomorphometric techniques. The thicknesses of the graft, epithelium, and sub-epithelial connective tissue were compared.

RESULTS

The samples from Group 3 and Groups 2 and 3 presented lower total and lower sub-epithelial connective tissue thickness, respectively, when compared with Group 1. The epithelial thickness was not affected by the dissection method. Muscular and adipose tissues were present in 77 and 55% of samples from Group 1, respectively, whereas these were observed in 44 and 22% of samples from Group 2 respectively. The muscular tissue was observed in 11% of the cases, and the adipose tissue was not observed in samples prepared with ultra-aggressive dissection.

CONCLUSION

We conclude that an intermediate graft dissection (whitish appearance, as performed in Group 2) presents the best balance between subepithelial connective tissue preservation and adipose and muscle tissue removal.

Oral mucosa grafting in periorbital reconstruction

To provide an extensive literature review on the clinical indications of oral mucosa grafts (OMG) and minor salivary gland grafts (MSGG) in periorbital reconstruction together with safe practice graft harvesting techniques to minimize donor-site morbidity. A literature review was performed by searching the databases of PUBMED, EMBASE, and COCHRANE library using the keywords: minor salivary glands; oral mucosal graft; orbit; and eye. The bibliographies of the pertinent articles were examined for additional papers. Indications for OMG include treatment of recurrent pterygia; socket contracture in anophthalmic patients; repair of eyelid deformities; ocular surface and fornix reconstruction following tumour resection, cicatricial ocular surface disorders, or chemical burns. More novel uses include repair of glaucoma aqueous drainage device erosions or leaking trabeculectomy blebs; scleral buckle exposure; and keratoprosthesis-related corneal melts as well as lining the dacryocystorhinostomy tract to prevent closure. Simultaneous MSGG transplantation may be used in the treatment of severe dry eyes or dry anophthalmic cavities. Harvesting from the inner cheek is preferred to lower lip as it causes less post-operative discomfort and neurosensory deficits. Suturing is recommended for smaller ovoid grafts as it allows less painful closure without tension, while larger rectangular defects are best left to heal by secondary intention. OMG and MSGG transplantation is a viable alternative to replace conjunctiva and restore the ocular surface. The donor site is readily accessible and widely available in most patients, grafting is fast and cheap, and the same site may undergo repeated harvesting with few donor site complications.

Buccal mucosa graft for simultaneous correction of severe chordee and urethroplasty as a one-stage repair of scrotal hypospadias (watch technique)

PURPOSE

Severe hypospadias repair still presents a great challenge. We evaluated a novel approach of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and new urethral plate creation, in combination with longitudinal dorsal island skin flap, as a one-stage repair of severe hypospadias.

METHODS

Between July 2014 and September 2017, 26 patients (aged from 12 to 22 months) underwent scrotal hypospadias repair. Short and non-elastic urethral plate is divided. Buccal mucosa graft is harvested from the inner cheek, and designed in a special "watch" shape, with the spherical part in the middle and two rectangular parts on both sides. Tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" buccal mucosa with 6-8 "U-shape" stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally. Longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with buccal graft. Penile skin reconstruction is performed using available penile skin.

RESULTS

The mean follow-up was 22 months (range from 9 to 46 months). Satisfactory results were achieved in 22 patients. Two urethral fistulas were successfully repaired by minor surgery after 3 months, while one meatal stenosis and one urethral diverticulum were successfully treated by temporary urethral dilation. There were no cases of residual curvature.

CONCLUSION

Specially shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty could be a good choice for single-stage repair of scrotal hypospadias with severe curvature.

Fiber density of collagen grafts impacts rabbit urethral regeneration

There is a need for efficient and “off-the-shelf” grafts in urethral reconstructive surgery. Currently available surgical techniques require harvesting of grafts from autologous sites, with increased risk of surgical complications and added patient discomfort. Therefore, a cost-effective and cell-free graft with adequate regenerative potential has a great chance to be translated into clinical practice. Tubular cell-free collagen grafts were prepared by varying the collagen density and fiber distribution, thereby creating a polarized low fiber density collagen graft (LD-graft). A uniform, high fiber density collagen graft (HD-graft) was engineered as a control. These two grafts were implanted to bridge a 2 cm long iatrogenic urethral defect in a rabbit model. Histology revealed that rabbits implanted with the LD-graft had a better smooth muscle regeneration compared to the HD-graft. The overall functional outcome assessed by contrast voiding cystourethrography showed patency of the urethra in 90% for the LD-graft and in 66.6% for the HD-graft. Functional regeneration of the rabbit implanted with the LD-graft could further be demonstrated by successful mating, resulting in healthy offspring. In conclusion, cell-free low-density polarized collagen grafts show better urethral regeneration than high-density collagen grafts.

Evaluation effect of low level Helium-Neon laser and Iranian propolis extract on Collagen Type I gene expression by human gingival fibroblasts: an in vitro study

BACK GROUND AND AIM

production of collagen by fibroblast cells is a key component in wound healing. Several studies have shown that low level laser therapy (LLLT) and propolis extract stimulate collagen Type I production. The aim of this study is to evaluation the combined effect of LLL helium neon (632.8 nm) and Iranian propolis extract on collagen Type I gene expression by human gingival fibroblasts (HGF3-PI 53).

METHODS AND MATERIALS

Human gingival fibroblasts after culturing divided into six experimental groups: G1-control group, which received no irradiation and propolis extract, G2-irradiated at1.5 J/cm², G3-irradiated at 0.15 J/cm², G4-recived extract of propolis, G5- combined extract of propolis and 1.5 J/cm² laser irradiation and G6- combined extract of propolis and 0.15 J/cm² laser irradiation. The experiments were conducted in triplicate. After 24 hour, the total RNA was extracted and cDNA synthesis was performed. Type I collagen mRNA expression was determined with real time PCR.

RESULTS

The obtained results illustrated a statistically significant difference between G3 (0.15 J/cm²) and G1 (control group) in levels of collagen Type I messenger RNA (mRNA) expression (p<0.05). The irradiated cells showed a 1.4 times increase in mRNA expression of the collagen Type I gene. Expression of this gene decreases in other groups that this difference was statistically significant.

CONCLUSION

LLLT in different dosage and propolis extract may result in decreased or increased collagen type I gene expression. However this effect should be investigated in clinical studies.

History and evolution of the use of oral mucosa for urethral reconstruction

We report here the history and evolution of the use of oral mucosa in reconstructive urethral surgery since it was first used for urethroplasty in 1894. Since that time, many authors have contributed to develop, improve and popularize the use of oral mucosa as a substitute material. Paediatric urologists should be considered pioneers on the use of oral mucosa as they used it to repair primary and failed hypospadias. The use of oral mucosa to repair penile and bulbar urethral strictures was described, for the first time, in 1993. Important evolutions in the technique for harvesting oral mucosa from the cheek were reported in 1996. Today, oral mucosa is considered the gold standard material for any type of anterior urethroplasty in a one- or two-stage repair due to its biological and structural characteristics that make it a highly versatile that is adaptable to any environment required by the reconstructive urethral surgery. As the future approaches, tissue engineering techniques will provide patients with new materials originating from the oral epithelial mucosal cells, which are cultured and expanded into a scaffold. However, the path to reach this ambitious objective is still long and many difficulties must be overcome along the way.

The long-term results of lingual mucosal grafts for repairing long anterior urethral strictures

Objective

To evaluate the long-term results of repairing long anterior urethral strictures with lingual mucosa onlay grafts.

Patients and methods

This study included 23 patients (mean age 36.3 years, range 21–62) who had a lingual mucosa onlay graft for managing a long anterior urethral stricture, and who were followed up for ⩾5 years. The mean length of the stricture was 4.6 cm. The International Prostate Symptom Score and uroflowmetry values were obtained before surgery, and at 3, 6 and 12 months afterwards, and annually thereafter. A retrograde urethrogram with a voiding cysto-urethrogram was taken before surgery, at catheter removal, after 3 and 6 months, and selectively thereafter.

Results

The mean (range) follow-up was 66 (60–72) months. The cause of the stricture was trauma in nine patients, instrumentation in seven, idiopathic in four, urethritis in two and previous hypospadias repair in one. The surgery was successful in 20 of the 23 patients (87%), and a recurrent stricture developed in the remaining three. There were no fistulae or clinically perceptible graft sacculations, and no long-term donor-site complications.

Conclusions

With a long-term follow-up, our series confirms the durability of lingual mucosal onlay grafts for treating long anterior urethral strictures. This procedure results in a long-term high success rate with few of the complications that occur primarily during the first year.

Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair

OBJECTIVES

To compare surgical outcomes and donor site complications of buccal and lingual mucosa used as ventral onlay graft for complex hypospadias cases.

PATIENTS & METHODS

Forty four cases with complex hypospadias after failed previous surgery were prospectively included. All had severely scarred penile skin with reasonable residual urethral plate. Cases were categorized into two groups: Group I (23) where buccal mucosal graft [BMG] was used and group II (21) where lingual mucosal graft [LMG] was used. Donor site complications as well as functional and esthetic outcomes were recorded for each group.

RESULTS

Mean follow up was 20.8 months (range 12-24). Average graft harvesting time was 24 min for BMG and 19 min for LMG. Donor site pain was reported with both techniques but recovery was earlier with LMG. Slurred speech and difficult tongue protrusion were reported with lingual but not buccal grafts; however mouth tightness, peri-oral numbness and persistent oral discomfort were reported only with buccal grafts. Successful urethroplasty was obtained in 78.2% of BMG compared to 76.1% of LMG.

CONCLUSION

Surgical outcomes of LMG urethroplasty were comparable to those of BMG in complex hypospadias cases. Compared to buccal mucosa, LMG is easy to harvest, with minimal donor site complications.

Prediction of early and late complications after oral mucosal graft harvesting: multivariable analysis from a cohort of 553 consecutive patients

PURPOSE

We investigated the early and late complications after oral mucosal graft harvesting, and reported the independent predictors of outcome via multivariable analysis.

MATERIALS AND METHODS

We performed a retrospective descriptive study of 553 patients from whom an oral mucosa graft was harvested for urethroplasty from single or bilateral cheeks. Patients who underwent oral mucosa harvesting from the lip, the tongue or from the cheek and lip at the same time were excluded from analysis. The oral graft was harvested in an ovoid shape with closure of the wound. Postoperative early and late complications were investigated using a self-administered, nonvalidated, semiquantitative questionnaire. There were 6 questions on early complications, and 13 questions investigated late complications and patient satisfaction.

RESULTS

Descriptive statistics of categorical variables focused on frequencies and proportions. Univariable and multivariable analyses were used to predict early and late dissatisfaction of patients. Bleeding was reported in 3.4% of patients. Overall 53.2% of patients did not report any pain and 36.3% reported no swelling. Late complications analysis showed that 95.5% of patients declared that the surgical closure of the wound did not cause any difficulty in opening the mouth or problems with smiling (98.2%) and/or dry mouth (95.8%). Overall 98.2% of patients were satisfied with the procedure. Univariable and multivariable analyses revealed that bilateral graft harvesting was the only significant predictor of patient dissatisfaction (OR 2.85, p = 0.01 and OR 2.72, p = 0.02; respectively).

CONCLUSIONS

Harvesting the oral mucosa ovoid graft from a single cheek with closure of the wound is a safe procedure with high rates of patient satisfaction.

Urethral strictures

What's known on the subject? and What does the study add? Urethral strictures are common and increasingly common in an ageing population. The treatment is controversial and particularly the relative roles of urethrotomy or urethral dilatation on the one hand and urethroplasty on the other. This review aims to provide a comprehensive overview of the subject including less commonly discussed issues such as the history and pathology of stricture disease. We would hope that a comprehensive overview of the subject will give a sharper perspective to aid the investigation and management of patients with urethral strictures.

Lingual mucosal grafts for anterior urethroplasty: a review

We critically reviewed recent reports of lingual mucosal grafts (LMGs) for substitution urethroplasty, to determine the efficacy and complications of this approach. Only a few centres have published the short or interim outcome of LMG urethroplasty. These studies dealt mainly with surgical techniques and harvesting LMGs, emphasizing the comparison of different intra-oral donor sites. The preliminary results seem to be encouraging for the safety and efficacy of LMG urethroplasty. When compared with other substitute materials, LMG give equally good results with much easier harvesting and minimal donor site morbidity. Thus, lingual mucosa is most likely to become an alternative to oral mucosa for substitution urethroplasty and longer term results of its use are awaited with interest.

What is the best technique for urethroplasty?

CONTEXT

There is no clear evidence that determines which type of urethroplasty to perform under which particular circumstance.

OBJECTIVE

To review the options for urethroplasty at different sites in the urethra and for different types of stricture indicating which procedure should be used in which circumstances according to the best available evidence.

EVIDENCE ACQUISITION

Recent publications have been reviewed and supplemented with the authors' personal experience.

EVIDENCE SYNTHESIS

Currently, in the developed world, the most common types of stricture are relatively short and are situated in the bulbar urethra. There is good evidence that these are best treated by excision and end-to-end anastomosis if they are short enough or by patch urethroplasty using a buccal mucosal graft if they are longer. Distal penile urethral strictures are the next most common type of stricture, but the evidence base is weaker, although there is agreement that penile strictures due to lichen sclerosus often require a staged approach to reconstruction, again using buccal mucosal grafts. Urethroplasty for pelvic fracture urethral injury is an altogether different type of technique for an altogether different type of pathology. There is good evidence that this is best treated by bulbo-prostatic anastomotic urethroplasty. Other types of strictures and salvage surgery have no good evidence base and are specialised areas where experience and judgement are necessary.

CONCLUSIONS

The evidence base for urethral surgery has been developed for the more common types of urethral strictures in the last 20 yr, but it is still as much an art as it is a science.

Muscle- and nerve-sparing bulbar urethroplasty: a new technique

BACKGROUND

To describe a new surgical technique for the repair of bulbar urethral strictures to preserve the bulbospongiosum muscle and its perineal innervation.

OBJECTIVE

Surgical steps of muscle- and nerve-sparing bulbar urethroplasty are described. The outcome is provided regarding semen sequestration and postvoiding dribbling.

DESIGN, SETTING, AND PARTICIPANTS

We performed the procedure in 12 patients (average age: 43.58 yr) with bulbar urethral strictures (average stricture length: 4.47 cm).

SURGICAL PROCEDURE

Six patients underwent urethroplasty using a ventral oral mucosal onlay graft, and six patients underwent urethroplasty using a dorsal oral mucosal onlay graft. In all patients, the surgical approach to the bulbar urethra was made avoiding dissection of the bulbospongiosum muscle from the corpus spongiosum and leaving the central tendon of the perineum intact.

MEASUREMENTS

Clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the technical feasibility of the muscle- and nerve-sparing bulbar urethroplasty. The secondary outcome examined the presence or absence of postoperative postvoid dribbling and semen sequestration using a nonvalidated questionnaire (Appendix).

RESULTS AND LIMITATIONS

In all patients, postoperative voiding cystourethrography was performed 3 wk after surgery and no urethral sacculation was evident. Urethrography were repeated after 6 mo and 12 mo. No postvoid dribbling or semen sequestration was demonstrated in all patients at 6 mo and 12 mo after surgery. No patient showed stricture recurrence. The average follow-up was 15.25 mo (range 12 mo to 26 mo, median 13.5 mo).

CONCLUSIONS

Bulbar urethroplasty preserving the bulbospongiosum muscle, the central tendon of the perineum, and the perineal nerves is a safe, feasible, minimally invasive alternative to traditional bulbar urethroplasty.