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

Erectile and Ejaculatory Function Following Anterior Urethroplasty: A Systematic Review and Meta-analysis

CONTEXT

The degree of change in erectile (EF) and ejaculatory function (EjF) according to validated questionnaires following anterior urethroplasty and different techniques is unclear.

OBJECTIVE

To investigate the evidence on EF and EjF evaluated via validated questionnaires following anterior urethroplasty.

EVIDENCE ACQUISITION

A systematic review (PROSPERO ID: CRD42021229797) of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The PubMed and CENTRAL databases were searched on February 1, 2021, with an updated search performed on December 1, 2021. Studies evaluating EF and/or EjF using validated questionnaires in men aged ≥18 yr following anterior urethroplasty were included.

EVIDENCE SYNTHESIS

Overall, 29 studies (two randomised and 27 nonrandomised) were included. The questionnaire most commonly used to evaluate EF and EjF was the International Index of Erectile Function (IIEF) and Male Sexual Health Questionnaire (MSHQ), respectively. The incidence of postoperative erectile dysfunction (ED) was 0-38% and the mean change in EF score according to the IIEF ranged from -4.0 to 2.5. The incidence of postoperative ejaculatory dysfunction (EjD) was 7.7-67% and the mean change in EjF score according to the MSHQ-EjD was 0.7-7.0. Meta-analyses revealed a mean difference of -0.87 (95% confidence interval [CI] -1.50 to -0.23; p = 0.008) in IIEF-EF score and 1.77 (95% CI 0.61-2.93; p = 0.003) in MSHQ-EjF score following anterior urethroplasty.

CONCLUSIONS

EF and EjF may be affected following anterior urethroplasty and men should be counselled appropriately. Owing to the variation in questionnaires and cutoff scores used, EF and EjF outcomes following different urethroplasty techniques are heterogeneous, with limited data from randomised controlled trials. An agreement on questionnaires and cutoff scores should be established to allow consistent reporting. Future research should aim to investigate best approaches for minimising sexual dysfunction.

PATIENT SUMMARY

Surgical repair of the urethra (urethroplasty) used to treat narrowing of the urethra (urethral stricture) may affect erectile and ejaculatory function. Different questionnaires and definitions are used to evaluate sexual function, so it is hard to compare data. The degree of disruption can be affected by different techniques and the severity of disease.

[Urethroplasties for male urethral strictures: Success rates and predictive factors]

INTRODUCTION

Urethroplasty has reported success rates ranging from 60 to 98%. Predictive factors for recurrence are rarely studied, postoperative urinary drainage modalities are not investigated. The primary objective was to evaluate the success rate of urethroplasty in our center. Secondary objectives were to identify recurrence predictive factors.

METHODS

A single-center retrospective cohort including men treated with urethroplasty for stricture between 2007-2017, followed up for a minimum of 12 months. Recurrence was defined as the necessity of a new procedure (endo-urethral or surgical). Data from penile urethra (SUP) and bulbo-membranous urethra (SUBM) stenosis were analyzed separately. Recurrence-free survival (success) was analyzed according to the Kaplan-Meier model. The characteristics of the patients, the stenosis, the surgical technique, the modalities of postoperative urinary drainage were analyzed in subgroups for the bulbo-membranous urethra looking for a correlation with recurrence.

RESULTS

A total of 103 patients included: 25 with SUP, 78 with SUBM. The overall success rate was 69%, CI95% [60-79] with a mean follow-up of 62.85 months. The success was 68%, CI95%[46-82] for SUP, 69.23%, CI95% [58-78] for SUBM. Recurrences occurred during the first 12 months. Only postoperative suprapubic urinary drainage was a predictive factor (HR=0.947, CI95% [0.905-0.992]). A period longer than 14 days reduced recurrence by 37%.

CONCLUSION

Urethroplasty had a success rate of 69%, comparable to published series. Suprapubic urinary drainage improved the surgery outcomes.

LEVEL OF PROOF

2, Grade B.

'Pee'BuSt Trial: A single-centre prospective randomized study comparing functional and anatomic outcomes after augmentation urethroplasty with penile skin graft versus buccal mucosa graft for anterior urethral stricture disease

Purpose

To assess the surgical outcomes of augmentation urethroplasty (AU) using penile skin graft (PSG) compared to buccal mucosa graft (BMG) in anterior urethral stricture disease.

Method

Between January 2018 and January 2019, 100 patients with anterior urethral stricture planned for AU were randomized into PSG or BMG arms (CTRI/2018/07/015028). Anatomic and functional variables were compared pre-operatively and post-operatively. Primary outcome was success rate at 18 months and it was defined if any of the three criteria were met, i.e. either maximum urinary flow (Qmax) > 15 ml/s or urethral calibration of 16 French or ability to traverse the repair with 17 French cystoscope. Secondary outcomes were functional parameters such as International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) Score, Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EJD), and Urethral Stricture Surgery-Patient Related Outcome Measure (USS-PROM).

Results

Pre-operative variables were comparable between both the arms. Median duration of follow-up was 22 months (18–24 months). At 18 months, the success rates of AU with PSG and BMG were comparable (89% v/s 91%; p = 0.70, 95% CI-0.33 to 5.21). The improvements in Qmax (p = 0.06), IPSS (p = 0.43) and USS-PROM (p = 0.49) were comparable between the two arms. There was no statistically significant difference in the IIEF-Erectile domain (p = 0.07), IIEF-Orgasmic domain (p = 0.11) and MSHQ-EJD (p = 0.20) following AU at 18 months. Clavien–Dindo grade I complications were 12.7% in PSG and 16.7% in BMG.

Conclusion

This study provides level 1 evidence of no statistical significant difference in outcomes of AU using BMG or PSG.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03843-x.

Sexual function after anterior urethroplasty: a systematic review

Background

Urethral surgery outcomes are often evaluated by assessing urinary flow and urethral patency. However, sexual consequences may appear after urethroplasty, impairing quality of life and patient’s perception of success.

The aim of this study is to assess the relationship between anterior urethral reconstruction and postoperative sexual dysfunction, including the proposed factors predicting sexual outcomes.

Methods

We searched in PubMed database using the terms: “anterior urethroplasty”, bulbar urethroplasty” or “penile urethroplasty”, and “sexual dysfunction”, “erectile function” or “ejaculation”. Articles were independently evaluated for inclusion based on predetermined criteria. Systematic data extraction was followed by a comprehensive summary of evidence.

Results

Thirty-eight studies were included for final analysis. No randomised trial on the topic was found. Urethral surgery might affect different aspects of sexual function: erectile function, ejaculatory function, penile shape and length, and genital sensitivity, leading to severe sexual dysfunction. Patient perception of sexual impairment was related to post-operative satisfaction.

Conclusions

Sexual dysfunction after anterior urethral reconstruction is an important issue that must be appropriately discussed during preoperative patient counselling. Reported outcomes after anterior urethroplasty should include sexual consequences and relevance, evaluated using validated tools.

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.

Long term outcomes of one-stage augmentation anterior urethroplasty: a systematic review and meta-analysis

OBJECTIVE

The objective is to summarize and characterize the long-term success of anterior augmentation urethroplasty (AU) in published series. The current literature on AU consists largely of retrospective series reporting intermediate follow-up and incompletely characterize the long term outcomes of AU.

MATERIALS AND METHODS

A systematic literature review was performed consistent with PRISMA guidelines to characterize long-term outcomes of AU with a minimum upper limit follow-up of 100 months. Penile/preputial skin flaps and graft and oral mucosal graft urethroplasties were included. The primary outcome was stricture-free survival for one-stage AU. Secondary analysis evaluated differences in outcomes based on two failure definitions: the need for intervention versus presence of recurrent stricture on cystoscopy or urethrography. Hazard rates were induced from the reported failure rates of one-stage AU and fixed and random effect models were fitted to the data. Additional subset analysis, removing potential confounders (lichen sclerosus, hypospadias and penile skin graft), was performed.

RESULTS

Ten studies met inclusion criteria, and two studies reported separate outcomes for grafts and flaps, and thus were included separately in the analysis. The mean hazard rate across all studies was 0.0044, the corresponding survival rates at 1 year 0.948, 5 years 0.766, 10 years 0.587, and 15 years 0.45. Subset analysis of the 4 select and homogeneous studies noted 1, 5, 10, and 15 years survival rates of 0.97, 0.96, 0.74, and 0.63, respectively.

CONCLUSIONS

The long-term success rates of augmentation urethroplasty are appear to be worse than previously appreciated and patients should be counseled accordingly. Available at. https://www.intbrazjurol.com.br/pdf/aop/2019-0242RW.pdf.

Dorsolateral inner preputial graft urethroplasty for anterior urethral strictures: long-term outcomes from a single tertiary care centre

Purpose

Buccal mucosa graft (BMG) is long used as favoured substitute by most reconstructive surgeons for substitution urethroplasty (SU). Though inner preputial skin graft (IPG) was described even earlier than BMG, its usage lately has fallen out of favour. The aim of the study was to evaluate the outcome of a SU with IPG from a tertiary care centre.

Methods

A retrospective analysis of prospectively maintained clinical data was conducted at our tertiary care centre enrolling 80 patients with anterior urethral stricture from January 2015 to January 2018. Patients were evaluated for the aetiology, length and site of the urethral stricture. All patients underwent dorsolateral SU with IPG. Post-operative assessment including uroflowmetry and sexual outcomes using IIEF and MSHQ-EJD questionnaires was done at 3 weeks, 3 months, 12 months and half-yearly thereafter. Success was defined by the stable maximum urinary flow value > 14 ml/s or urethral calibration with 16 French Foley catheter.

Results

Mean age of patients was 40 years (18–69). The most common aetiology was post-instrumentation (65%) and 60% had stricture at penobulbar site. Mean stricture length was 65 mm. At a mean follow-up of 48 months (range 30–66 months), successful outcomes were seen in 69/80 (87%). Patients with failure were managed with optical internal urethrotomy (OIU). Uroflowmetry and obstructive symptoms significantly improved and sexual function remained unaffected using IPG for SU.

Conclusions

Preputial graft is a tissue familiar to the urologist, located very close to the surgical field, easily harvested and operated under regional anaesthesia. Overall success outcomes are acceptable to BMG urethroplasty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03613-9.

Minimally Invasive Buccal Mucosa Dorsal Graft for Female Distal Urethroplasty

Background

Female urethral stricture (FUS) represents a sporadic condition. There is a lack of data and standardized guidelines on diagnostics and therapeutics. Several surgical techniques have been described for FUS urethroplasty, among which the flap-based or graft-based ones are most reported. Buccal mucosa graft (BMG) represents the gold standard for male urethroplasty, and this can theoretically be applied also to FUS treatment.

Objective

To describe and present preliminary results of a novel minimally invasive technique for buccal mucosa dorsal graft (mini-dorsal BMG) urethroplasty for the treatment of FUS.

Design, setting, and participants

This is a retrospective study on buccal mucosa dorsal graft urethroplasty for the treatment of FUS.

Surgical procedure

Every patient was placed in lithotomic position. Two stiches were placed at 10 and 2 o’clock positions to facilitate the dorsal median urethrotomy. The margins of the incised dorsal urethra at the 12 o’clock position are then dissected from the periurethral tissue. This dissection results in an elliptical raw area between the edges of the urethra over the periurethral tissue. The harvested BMG was fixed with several quilting sutures, using 5-0 and 4-0 absorbable sutures, to cover the raw area. The margins of the graft were sutured to the edges of the incised urethra.

Measurements

A chart review was performed.

Results and limitations

Thirteen patients underwent the mini-dorsal-BMG technique. The median preoperative uroflow was 5.6 (3–13) ml/s, and the median postoperative value was 23.4 (14–58) ml/s.

Conclusions

The mini-dorsal-BMG technique for the treatment of FUS gives good results with low complication rates. Other series and long-term follow-up are necessary to confirm the reproducibility of this technique.

Patient summary

We present the technical aspects and the promising preliminary results of a novel surgical technique for the treatment of female urethral stricture by using the buccal mucosa to correct this invalidating disease.

Dorsal onlay buccal mucosa graft urethroplasty for bulbar urethral stricture: a single centre experience

Introduction

the successful treatment for urethral strictures demands not just attention to surgical details but careful selection of the reconstructive technique. For long segment urethral strictures substitution urethroplasty is required. This study sought to determine the success rate and complications of dorsal onlay buccal mucosal graft (BMG) urethroplasty for long segment urethral strictures in our hospital.

Methods

this was a retrospective study carried out at Jos University Teaching Hospital from March 2015 to March 2018. The case notes of male patients who had dorsal onlay buccal mucosal graft urethroplasty for long segment bulbar urethral stricture within the study period were retrieved. Patients´ demographics, cause and nature of urethral strictures, duration of follow up, the success rate and complications were collected and subjected to statistical analysis using SPSS® version 22.

Results

twenty-four men with mean age of 45 years (range 14-67 years) had dorsal onlay buccal mucosal graft urethroplasty during the study period. The mean stricture length was 4.5cm (range, 2-7cm). After a mean follow up duration of 2 years (range, 1 4 years), 21(87.5%) patients had a successful urethroplasty as they were able to pass urine at one year post urethroplasty without lower urinary tract symptoms, while 3(12.5%) had recurrence of the urethral stricture. At the recipient site, 2(8.3%) patients had primary bleeding that did not require blood transfusion. Also, 2(8.3%) patients had superficial wound infection which was treated with antibiotics. At the donor site, 4(16.7%), 2(8.3%), 4(16.7%) had donor site swelling, transient bleeding and soreness respectively.

Conclusion

dorsal onlay BMG urethroplasty has a good success rate and minor complications and therefore suitable for long segment bulbar urethral strictures.

Buccal mucosa or penile skin for substitution urethroplasty: A systematic review and meta-analysis

Penile skin (PSG) and the buccal mucosa (BMGs) are the most commonly used grafts for substitution urethroplasty. The aim of this study was to compare the success rates of substitution urethroplasty using either of these grafts. We systematically searched PubMed/Medline, EMBASE, Scopus and Web of science to identify studies comparing the two types of graft urethroplasties. Search strategy was based on Patient, Intervention, Control and Outcome guidelines. Studies reporting data on success of PSG versus BMG within the same manuscript were included. Standard Preferred reporting Items for Systematic reviews and Metaanalysis guidelines were followed while conducting this review and study protocol was registered with PROSPERO in priori (CRD42018114258). Sixteen studies, including 5 prospective and 11 retrospective studies, with a total of 1406 (896 BMG and 510 PSG) patients were included in the final analysis. In the overall analysis, BMG had significantly higher success rate (83.7% vs. 76.1%, P ≤ 0.0001). Duration of followup was heterogeneous across the studies, ranging from 15.9 to 201 months. Comparing the five studies where the data on duration of follow up was available, BMG showed a significantly higher success rate compared to PSG (90% vs. 80.4%; P = 0.02). In the subgroup of patients with bulbar urethral strictures, BMG urethroplasty had significantly higher success rate (87.4% vs. 78.0%; P = 0.0001). From the results of this study, buccal mucosa may appear to be a better choice, however, the data is still immature and a properly conducted randomized controlled trial with an adequate duration of followup is required.

Changing Trends in Reconstruction of Complex Anterior Urethral Strictures: From Skin Flap to Perineal Urethrostomy

OBJECTIVE

To evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade.

METHODS

We retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management.

RESULTS

Among 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%).

CONCLUSION

Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps.

Twin penile skin flap, is it the answer for repair of long anterior urethral strictures?

Objective

To present our twin ventral penile skin flap technique for the management of complex long anterior urethral strictures not caused by lichen sclerosis (LS), with evaluation of surgical outcome and complications.

Patients and methods

We retrospectively reviewed patients diagnosed with long complex anterior urethral strictures who were all referred to Ain Shams University hospital and operated on by three reconstructive surgeons. The surgical procedure was carried out as follows: exposure of the urethra through a ventral longitudinal penile skin incision and another perineal incision; two ventral longitudinal dartos-based penile skin flaps are used for urethral augmentation as onlay flaps. Clinical data were collected in a dedicated database. Preoperative, intraoperative, and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed.

Results

Between January 2012 and February 2015, 47 patients diagnosed by urethrograms as having long anterior urethral strictures, with a mean (SD, range) length of 17.56 (2.09; 14-21) cm, were managed by twin penile skin flap repair. Four patients were lost to follow-up, thus 43 patients constituted the study cohort. The mean (range) follow-up period was 31 (22-36) months. The overall success rate was 95.35% (41/43). At 12-months postoperatively, the 41 successful cases had a mean (SD, range) peak urinary flow rate of 20.26 (3.06, 14-25) mL/s and American Urological Association Symptom Score of 5.6 (1.85, 3-8). Postoperative complications included urethrocutaneous fistula in three patients (6.97%), mild sacculation of the flap in seven patients (16.52%), post-micturition dribbling in 34 patients (79.07%), decreased penile girth in two patients (4.65%), and chordae of <15° with no need for repair in three patients (6.97%).

Conclusions

In the presence of a favourable urethral plate and ample non-hirsute penile skin, one-stage twin penile skin flap urethroplasty provides excellent results for non-LS related complex strictures, with minimal acceptable complications. It proved to be especially efficient in circumcised patients.

[Analysis of success rates of uretroplasty for adult male bulbar urethral stricture: A systematic review]

Male urethral stricture disease is prevalent and has an important impact on quality of life. Direct visual urethrotomy and dilatations have high rates of recurrence.

OBJECTIVES

The aim of this review of literature was to evaluate the success rates of different techniques of urethroplasty for strictures of the bulbar urethra.

METHODS

We performed a systematic review of the MEDLINE literature from 2004 to 2015 following the PRISMA's statement recommendations. Key words were: urethroplasty, urethral reconstruction, onlay, graft, urethral stricture. Inclusion criteria were original articles describing the results of urethroplasty for bulbar urethral stricture in an adult male population. A minimum follow-up of 24 months was required.

RESULTS

From 891 articles of the literature, 20 are studied in this review. Only 3 studies were prospective. The success rate of anastomotic urethroplasty varied from 68.7 to 98.8% for strictures from 1 to 3.5cm, from 60 to 96.9% for augmented urethroplasty performed for strictures from 4.2 to 4.7cm. Substitution urethroplasty with grafts presented from 75 to 89.8% of success for strictures from 2.6 and 4.36cm. Overall, 19/20 studies used buccal mucosal graft.

CONCLUSION

The success rate of urethroplasty for bulbar urethral stricture is high; the surgical technique should be adapted to the length of the stricture.

Sexual (Dys)function after Urethroplasty

There is a paucity of published literature on the andrological consequences of urethral repair. Until recently authors have focused mainly on technical aspects and objective results. Reported outcomes of urethral reconstruction surgery have traditionally focused only on urodynamic parameters such as flow rates. Patient reported outcome measures have largely been neglected and there is a scarcity of well conducted systematic studies on the subject. For these reasons whether the different components of sexual life are more or less affected by different types of urethral reconstruction remains largely unknown. In an attempt to clarify the available scientific evidence, the authors make a critical review of available literature, systematizing it by sexual domain and study type. Brief pathophysiological correlations are discussed.

SIU/ICUD Consultation on Urethral Strictures: The management of anterior urethral stricture disease using substitution urethroplasty

In this systematic review of the literature, a search of the PubMed database was conducted to identify articles dealing with augmentation/substitution urethral reconstruction of the anterior urethral stricture. The evidence was categorized by stricture site, surgical technique, and the type of tissue used. The committee appointed by the International Consultation on Urological Disease reviewed this data and produced a consensus statement relating to the augmentation and substitution of the anterior urethra. In this review article, the background pathophysiology is discussed. Most cases of urethral stricture disease in the anterior urethra are consequent on an ischemic spongiofibrosis. The choice of technique and the surgical approach are discussed along with the potential pros and cons of the use of a graft vs a flap. There is research potential for tissue engineering. The efficacy of the surgical approach to the urethra is reviewed. Whenever possible, a 1-stage approach is preferable from the patient's perspective. In some cases, with complex penile urethral strictures, a 2-stage procedure might be appropriate, and there is an important potential role for the use of a perineal urethrostomy in cases where there is an extensive anterior urethral stricture or where the patient does not wish to undergo complex surgery, or medical contraindications make this hazardous. It is important to have accurate outcome measures for the follow-up of patients, and in this context, a full account needs to be taken of patients' perspectives by the use of appropriate patient-reported outcome measures. The use of symptoms and a flow rate can be misleading. It is well established that with a normally functioning bladder, the flow rate does not diminish until the caliber of the urethra falls below 10F. The most accurate means of following up patients after stricture surgery are by the use of endoscopy or visualization by urethrography. Careful consideration needs to be made of the outcomes reported in the world literature, bearing in mind these aforementioned points. The article concludes with an overview of the key recommendations provided by the committee.

Nontransected ventral onlay-augmented urethroplasty using autologous saphenous vein graft in a rabbit model of urethral stricture

OBJECTIVE

To evaluate the efficacy and feasibility of nontransected ventral onlay-augmented urethroplasty using an autologous saphenous vein graft in a rabbit model of urethral stricture.

METHODS

Ten white male rabbits weighing 3.0-3.5 kg were selected, and a long tract urethral stricture was generated by excising an 0.8-cm wide and 2-cm long portion of the distal urethra. One month after the procedure, the rabbits were randomized into a urethral stricture group (n = 5) or urethroplasty with saphenous vein graft group (n = 5). Another 5 rabbits served as a normal control group. Retrograde urethrography was performed at 2, 4, 8, and 12 weeks after surgery in all groups, and the rabbits were killed at 12 weeks postoperatively for histopathologic and immunohistochemical evaluation.

RESULTS

The mean operated urethral width of the normal, stricture, and vein graft group was 10.2 ± 0.84, 4.3 ± 0.97, and 10.04 ± 2.35 mm at 2 weeks postoperatively, respectively (P = .008). The 4-, 8-, and 12-week postoperative urethrograms revealed results similar to those of the 2-week postoperative urethrograms. Histologic analysis showed the neourethra was epithelialized with urothelium in the vein graft group. All the rabbits survived throughout the study period without fistula formation or infection.

CONCLUSION

Nontransected ventral onlay-augmented urethroplasty using an autologous saphenous vein graft can be an effective and feasible procedure for the surgical management of long tract urethral stricture.

Long anterior urethral stricture: Reconstruction by dorsally quilted penile skin flap

OBJECTIVES

We'd like to present our experience in treating long (>5 cm) anterior urethral stricture by penile skin flap as dorsal on-lay in one-stage procedure.

PATIENT AND METHODS

Between January 1998 and December 2010, 18 patients (aged from 28-65 years) presented with long urethral stricture, 5.6-13.2 cm, (penile in 6, bulbar in 2, and combined in 10 cases), those were repaired utilizing long penile skin flaps placed as dorsal on-lay flap in one-stage (Orandi flap 6 cm in 6 cases, circular flaps 7-10 cm in 8, and spiral flaps 10-15 cm in 4). Uroflowmetry and RUG were done following catheter removal and at 6 and 12 months.

RESULTS

The urethral patency was achieved in 77% of patients. The complications were fistula in 1 patient (5.5%), re-stricture occurred in 3 patients (16.6%) that required visual internal urethrotomy (VIU), and 2 patients (11%) showed curvature on erection that did not interfere with sexual intercourse. Diverticulum (penile urethra) was seen in 1 patient (5.5%) containing stones and was excised surgically. There was penile skin loss in 3 patients (16.6%). All patients completed at least one year follow-up period.

CONCLUSION

Free penile skin flaps offer good results (functional and cosmetic) in long anterior urethral stricture. Meticulously fashioned longitudinal, circular or spiral penile skin flaps could bridge urethral defects up to 15 cm long.

De novo erectile dysfunction after anterior urethroplasty: a systematic review and meta-analysis

OBJECTIVE

To evaluate the likelihood of developing de novo erectile dysfunction (ED) after anterior urethroplasty and to determine if this likelihood is influenced by age, stricture length, number of previous procedures or timing of evaluation.

MATERIALS AND METHODS

PubMed, Embase, Cochrane, and Google Scholar databases were searched for the terms 'urethroplasty', 'urethral obstruction', 'urethral stricture', 'sexual function', 'erection', 'erectile function', 'erectile dysfunction', 'impotence' and 'sexual dysfunction'. Two reviewers evaluated articles for inclusion based on predetermined criteria.

RESULTS

In a meta-analysis of 36 studies with a total of 2323 patients, de novo ED was rare, with an incidence of 1%. In studies that assessed postoperative erectile function at more than one time point, ED was transient and resolved at between 6 and 12 months in 86% of cases.

CONCLUSIONS

Men should be counselled regarding the possibility of transient or permanent de novo ED after anterior urethroplasty procedures. Increasing mean age was associated with an increased likelihood of de novo ED, but this was not statistically significant.

[Oral mucosa for reconstructive urethral surgery]

The use of oral mucosa for urethral stricture repair has become the standard approach in reconstructive urethral surgery. Compared to other tissues oral mucosa shows several advantages, such as simple harvesting, good urine tolerance and low harvesting morbidity. For defects of the male bulbar urethra measuring 2 cm or longer, urethral reconstruction with oral mucosa is the procedure of choice. The oral mucosa graft can be used as an inlay or as an onlay graft. Most repairs can be completed in one stage but for complex strictures two stages are needed.

Low risk of sexual dysfunction after transection and nontransection urethroplasty for bulbar urethral stricture

PURPOSE

Open urethroplasty is the preferred treatment for recurrent bulbar urethral stricture. However, there are still some controversies regarding the optimal technique and the consequences of transecting the urethra in terms of sexual dysfunction, such as erectile dysfunction, penile shortening, impaired glans filling, decreased glans sensibility and ejaculatory function. We performed a retrospective analysis with long-term followup of anastomotic and substitution onlay urethroplasty in bulbar strictures with an emphasis on postoperative sexual function.

MATERIALS AND METHODS

A total of 169 patients with bulbar stricture were treated with urethroplasty via the onlay technique (75) or resection followed by end-to-end anastomosis (94) during 1999 to 2009. Mean followup in the transection and onlay groups was 41 and 69 months, respectively (range 12 to 132). All patients were asked verbally about sexual function during followup. Failure was defined as the need for new surgical intervention.

RESULTS

Erectile dysfunction developed in 1 patient (1%) per group. In the transection group 5 patients (5%), including 4 with longer and more distal strictures, had penile shortening/downward angulation. However, this did not interfere with sexual ability during intercourse. No patient reported impaired glans or ejaculatory function. The success rate in the transection and onlay groups was 91% and 71%, respectively.

CONCLUSIONS

Transection with resection and end-to-end anastomosis is a good method for bulbar stricture with a low rate of sexual dysfunction and a high success rate postoperatively. To avoid penile angulation/shortening, it might be wise to use the onlay technique for longer and distal strictures.

Urethral reconstruction using allogenic frozen-thawed bladder mucosa: an experimental study

OBJECTIVE

To determine the feasibility and effectivity of allogenic frozen-thawed bladder mucosa for urethroplasty.

METHODS

Bladder mucosa was harvested from 6 New Zealand rabbits. Changes in the bladder mucosa as seen by histological and electron microscope examination were compared between the frozen-thawed and fresh groups. Twelve urethral stricture models were established and randomly divided into two groups. In the test group, we performed urethroplasty with allogenic frozen-thawed bladder mucosa, and the same operation was done in the control group, but using fresh bladder mucosa. The result of retrograde urethrography and histological changes of the urethral sample were compared postoperatively.

RESULTS

No obvious changes on histological and electron microscope examination were observed in the frozen-thawed bladder mucosa. Inflammation reaction of the surgical site in the test group was milder than that of the controls 2 weeks after surgery. The urethral epithelial cells grew well 2 weeks after surgery, but lots of epithelia were necrotic in the control group. The urethra of all rabbits in the test group had good continuity and the urethral lumen was large in the test group 2 months after surgery. There was a layer of urethral epithelium in the test group 2 months after surgery, whereas scar tissue was found in the control group.

CONCLUSIONS

The freeze-thaw technique can maintain bladder mucosa structure and biological function. Frozen-thawed allogenic bladder mucosa may be a potential material for urethroplasty.

'Minipatch' penile skin graft urethroplasty in the era of buccal mucosal grafting

Objectives

To describe our experience with ‘minipatch’ penile skin graft (PSG) urethroplasty, as at our institution we prefer excision and primary anastomosis (EPA) urethroplasty whenever feasible, as it gives better outcomes than substitution urethroplasty. However, despite careful preoperative planning, the unanticipated need for a small graft is occasionally recognised intra-operatively, and in such cases we have found that harvesting a minipatch is an efficient alternative to harvesting a buccal mucosal graft.

Patients and methods

Bulbar urethroplasty using a <3 cm PSG was performed via either a ventral onlay or augmented anastomotic technique. In each case the PSG was required to repair an unanticipated urethral defect recognised intra-operatively during various scenarios of challenging urethroplasty. We retrospectively reviewed our experience with this technique.

Results

Among a total of 425 urethral reconstructions over a 4-year period at our institution, four patients (1%) underwent minipatch PSG urethroplasty to repair either urethral strictures that were discovered intra-operatively to be too complex for EPA (two patients) or for intra-operatively identified, unanticipated synchronous strictures (two patients). The mean (range) stricture length was 2.4 (2–3) cm and the mean graft length was 2.1 (1.5–2.5) cm. At a mean follow-up of 18 months all repairs were patent with no need for further procedures or instrumentation.

Conclusion

Minipatch PSG urethroplasty is an efficient alternative to a buccal mucosal graft repair, especially when the unanticipated need for short-segment tissue transfer arises during complex urethral reconstruction.

Critical review of existing patient reported outcome measures after male anterior urethroplasty

PURPOSE

Male urethral stricture disease can be recurrent and debilitating. The aim of any intervention is to allow men to return to a normal state of voiding while maintaining a strong quality of life. A systematic review of the literature was conducted to assess for the use of patient reported outcome instruments after male anterior urethroplasty.

MATERIALS AND METHODS

A review of PubMed® was conducted to identify studies that used a patient reported outcome measure to assess patient outcome after open surgical correction of male strictures. Preference was given to studies that used an instrument in the preoperative and postoperative setting. However, use of an outcome measure solely in the postoperative setting was also accepted. After article selection, the 8 attributes recommended by the Scientific Advisory Committee were used to analyze the measurement properties of each patient reported outcome measure.

RESULTS

A total of 15 studies were identified that included an instrument to assess patients with anterior urethral strictures. The studies used differing instruments to assess anterior urethral strictures in a nonuniform manner. Four studies used a lower urinary tract symptoms instrument, 8 used a sexual/ejaculatory dysfunction instrument, and 3 used a lower urinary tract symptoms and sexual/ejaculatory function instrument. There was only 1 report that described the development of a urethroplasty specific patient reported outcome instrument.

CONCLUSIONS

Continued effort is necessary to develop a powerful instrument to assess patient reported outcomes after male urethroplasty. The importance of patient perspective is vital to understanding the success of open urethral reconstruction.

Urethral reconstruction using buccal mucosa or penile skin grafts: systematic review and meta-analysis

INTRODUCTION

Different types of grafts have been described in urethral reconstruction (UR), with penile skin graft (PSG) and buccal mucosa graft (BMG) as the most frequently used ones. It still remains unclear whether one graft is superior in terms of success when compared to the other.

MATERIAL AND METHODS

A systematic review of the literature was performed searching the MEDLINE database with the following search strategy: 'urethroplasty' AND 'penile skin'/ 'urethroplasty' AND 'buccal mucosa'. 266 and 144 records were retrieved for urethroplasty with PSG and BMG, respectively. These records were reviewed to identify papers where PSG and BMG were used in UR and where individualized data on success were available within the same series.

RESULTS

18 papers were found eligible for further analysis. In total, 428 and 483 patients were respectively treated with PSG or BMG. If available, follow-up duration was 64.1 versus 42.1 months (p < 0.0001) and stricture length 6.2 versus 4.6 cm (p < 0.0001) for PSG and BMG, respectively. Success of UR with PSG was 81.8 versus 85.9% with BMG (p = 0.01).

CONCLUSIONS

Success of UR using BMG is significantly better compared to PSG. Results might be seriously biased by a longer follow-up duration and stricture length for PSG compared to BMG.

Preputial/penile skin flap, as a dorsal onlay or tubularized flap: a versatile substitute for complex anterior urethral stricture

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? For long complex anterior urethral stricture augmentation urethroplasty is considered the standard procedure but the best substitute material is still to be ascertained. Preputial/penile skin is a very good substitute especially when used as a dorsal onlay. It demonstrates exceptional functional and cosmetic results even in patients with unsuitable oral mucosa.

OBJECTIVE

• To present our experience of single-stage reconstruction of urethral stricture with preputial/penile skin flap, as a dorsal onlay flap (DOF) where there is an adequate urethral plate and as a tubularized flap (TF) where there is a compromised urethral plate, in cases of complex anterior urethral strictures.

MATERIALS AND METHODS

• We retrospectively reviewed 144 patients, who underwent single-stage repair of pendular /bulbar urethral strictures with preputial/penile flap as either a DOF or a TF, between January 2001 and December 2008. • Patients were divided into three groups: Group 1 consisted of patients who underwent transverse preputial DOF; Group 2 consisted of those who underwent tube urethroplasty; and Group 3 consisted of those patients who were circumcised and for whom the penile skin was used as a DOF (circumpenile flap). • Patients were followed up by physical examination, retrograde urethrography, uroflowmetry and post-void residual urine measurement.

RESULTS

• The mean follow-up was 40.1 months (range 36-84 months). • The primary success rates at 1 year follow-up were 90, 85 and 93.3% for Groups1, 2 and 3, respectively, and at 3-years follow-up they were 85, 75 and 86.7%, respectively. • Half of the recurrences were successfully managed with a single visual internal urethrotomy or dilatation. • The secondary success rate was defined as recurrent stricture managed by a single endoscopic procedure and was 5, 10 and 6.8% in Groups 1, 2 and 3, respectively. The overall success rate was 90.85 and 93.3%, respectively. • A total of 75% of the patients in the study completed 60 months of follow-up with no additional recurrence.

CONCLUSIONS

• A preputial/penile flap for complex anterior urethral stricture is a good treatment option, with results similar to other techniques, has acceptable donor site morbidity and is effective even in circumcised patients and for those patients with unsuitable oral mucosa. • A DOF is less likely to lead to diverticula formation and post-void dribbling. TFs have a higher failure rate than DOFs but, when combined judiciously with secondary endoscopic procedures, can provide good results.

Reconstruction of long anterior urethral strictures by dorsally quilted penile skin flap

Objective. To present the results of reconstruction of long (>5 cm), penile, bulbar, and bulbopenile urethral strictures by penile skin flap as dorsal onlay in one-stage procedure. Patients and Methods. Between January, 1998 and December, 2004, 18 patients (aged from 28-65 years) presented with long urethral strictures, 5.6–13.2 cm (penile in 6, bulbar in 2 and combined in 10 cases), those were repaired utilizing long penile skin flaps placed as dorsal onlay flap in one stage (Orandi flap 6 cm in 6 cases, circular flaps 7–10 cm in 8, and spiral flaps 10–15 cm in 4). Followup of all patients after reconstruction included urine flow rate at weekly intervals, RUG at 6–12 weeks, and urethrocystoscopy at 12 and 18 months. Results. The urethral patency was achieved in 77% of patients. The complications were fistula in one patient (5.5%), restricture occurred in 3 patients (16.6%) that required visual internal urethrotomy and two patients (11%) showed curvature on erection that dose not interfere with sexual intercourse. Diverticulum (penile urethra) was seen in one patient (5.5%) containing stones and was excised surgically. There was penile skin loss in 3 patients (16.6%). All patients completed at least one-year followup period. Conclusion. Free penile skin flaps offer good results (functional and cosmetic) in long penile and/or bulbar urethral strictures. Meticulously fashioned longitudinal, circular or spiral penile skin flaps could bridge urethral defects up to 15 cm long.

The effect of programmed cryopreservation on immunogenicity of bladder mucosa in New Zealand rabbits

A significant reduction in immunogenicity has been observed in some frozen-thawed tissues after cryopreservation. The objective of this study was to evaluate the effects of programmed cryopreservation on immunogenicity of rabbit bladder mucosa and on the extent of immunological rejection caused by the allograft. This study would provide theoretical support for the application of allogenic frozen-thawed bladder mucosa in the treatment of urethral stricture. Forty-two adult male New Zealand rabbits were used in this study. The immunogenicity was detected by mixed lymphocyte reaction using the allograft of bladder mucosa (fresh and frozen-thawed) and spleen lymphocytes. Twelve urethral stricture models were established in New Zealand rabbits for substitution urethroplasty using the allograft of bladder mucosa, which were divided into fresh and frozen-thawed group. Two weeks after operation, lymphocyte proliferation was detected in both blood and spleen of recipient rabbits. At the same time, immunohistochemical staining of urethral allograft was performed and the expression of CD3, CD4 and CD8 were observed. The mRNA of bladder mucosa (fresh and frozen-thawed) was extracted and the expressions of RLA-I, RLA-II and RLA-III gene were detected by real-time PCR. By mixed lymphocyte reaction, we found that allogenic lymphocyte proliferation stimulated by frozen-thawed bladder epithelial cells was significantly weaker than that of the fresh cells. The blood and spleen lymphocytes from fresh bladder mucosa group showed significantly higher proliferation rate than frozen-thawed group. Compared with the fresh group, the expression of CD3+ and CD8+ T cells infiltrated in the operation locus of bladder mucosa urethroplasty was significantly decreased in the frozen-thawed group. However, the expressions of RLA genes did not change significantly after the freeze-thaw procedure. This study demonstrates for the first time that a programmed freeze-thaw procedure of rabbit bladder mucosa could reduce its immunogenicity in allogenic bladder mucosa urethroplasty and thus restrict the extent of immunological rejection, therefore, provides theoretical support for the application of frozen-thawed bladder mucosa in the treatment of urethral stricture.

Preputial skin free graft as dorsal onlay urethroplasty: Our experience of 73 patients

Objective:

To present the outcome of dorsal onlay urethroplasty in 73 patients for stricture urethra over a period of eight years.

Materials and Methods:

Seventy-three patients of stricture urethra have undergone dorsal onlay urethroplasty from July 1998 to February 2006. Age distribution: 14-58 years. Etiology: Trauma 20/73 (27.39%), Balanitis Xerotica Obliterans 2/73 (2.73%), Iatrogenic 26/73(35.61%), Infection 3/73 (4.10%), Idiopathic 22/73 (30.13%). Site: Penobulbar-25/73, bulbar-38/73, membranous-8/73 and long length-2/73. Suprapubic catheter was inserted preoperatively: 21/73 patients. Preputial / distal penile skin was used in all patients. Buccal mucosa was not used in any patient. Hospitalization was for four to five days. Catheter was removed after 21 days. All patients had their first endoscopic checkup after three months. Subsequently they were followed up by uroflometry. Routine imaging of urethra for follow-up was not carried out.

Results:

63/73 (86.30%) patients had satisfactory outcome not requiring any further treatment, 8/73 (10.95%) developed anastomotic stricture (3/8-optical internal urethrotomy, 5/8 dilatation alone). 2/73 (2.75%) developed external meatal stenosis. None had urinary fistula and required repeat urethroplasty. Follow-up ranged from three months to eight years.

Conclusion:

Dorsal onlay urethroplasty using preputial/distal penile skin is a satisfactory procedure. Preputial/distal penile skin is devoid of hair and fat and hence an ideal graft material. Even in circumscribed patients distal penile skin can be harvested. Long-term follow-up is required in judging results of patients with stricture urethra.

Aptness and complications of labial mucosa grafts for the repair of anterior urethral defects in children and adults: single centre experience with 115 cases

PURPOSE

We report a comprehensive review of our experience with labial mucosa graft urethroplasty to evaluate the indications for this kind of substitution urethroplasty, and the possible complications and risk factors for an untoward recipient site outcome both in children and adults.

MATERIALS AND METHODS

Complications were retrospectively assessed by chart review. Patients with and without complications were compared with respect to age at surgery, indication for surgery (epispadias vs. hypospadias vs. urethral stricture), graft length and configuration (tube vs. patch). Moreover, in cases with urethral stricture a comparison was made according to the level of the stricture (penile vs. bulbar).

RESULTS

After a median follow-up of 36 (6–90) months, the overall success rate was 66%. Complications were observed in 39 (34%) patients, of whom 18 (16%) required additional surgical procedures. Complications appeared to be unrelated to patient age at surgery, indication for surgery, graft length, and the urethral level of the stricture. Use of the graft as a tube was the single factor significantly more frequent in patients experiencing complications, particularly in the urethral defects associated with hypospadias where use of a tube corresponded to an odd ratio of 5.86 (95% CI 1.5–23.4).

CONCLUSIONS

Oral grafts harvested from the lower lip are a versatile tissue for the repair of urethral defects associated with either urethral malformations or strictures, both in children and adults. Use of the graft as an on-lay seems preferable particularly in hypospadias repairs.

The impact of urethroplasty on voiding symptoms and sexual function

OBJECTIVE

To determine the effect of urethroplasty for urethral stricture disease on both voiding symptoms and sexual function through the use of validated patient questionnaires.

METHODS

Pre- and post-operative scores for the American Urological Association Symptom Index (AUASI), Incontinence Symptom Index (ISI), and Sexual Health Inventory for Men (SHIM) were obtained and compared for adult male patients undergoing urethroplasty. Score differences were then stratified by age. Relevant clinical and demographic characteristics were also examined.

RESULTS

Over the 15-year study period, 183 patients underwent 222 urethroplasties. Median age at the time of surgery was 45 years. Urethroplasties were performed for 207 anterior and 15 posterior urethral strictures. The most common approaches were primary anastomotic (36.5%), staged (23.9%), and buccal graft augmented (21.6%). Overall, 63% of men had a clinically meaningful (≥4 point) improvement in AUASI total score and 69% had improvement in their quality of life (QOL) score after urethroplasty. In aggregate, AUASI total scores improved by 7 points (P<.001), and QOL scores improved by 2 points (P<.001). There was no significant difference in ISI or SHIM scores before and after urethroplasty. AUASI total scores improved more dramatically in younger patients. Half of patients with improved AUASI QOL scores did not have a corollary improvement in their total score.

CONCLUSIONS

As measured by validated questionnaires, patients of all ages can expect a meaningful improvement in bothersome voiding symptoms after urethroplasty for urethral stricture disease, with minimal impact on continence or erectile function.

A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures

CONTEXT

Reconstructive surgeons who perform urethroplasty have a variety of techniques in their armamentarium that may be used according to factors such as aetiology, stricture position, and length. No one technique is recommended.

OBJECTIVE

Our aim was to assess the reported outcomes of the various techniques for graft augmentation urethroplasty according to site of surgery.

EVIDENCE ACQUISITION

We performed an updated systematic review of the Medline literature from 1985 to date and classified the data according to the site of surgery and technique used. Data are also presented on the type of graft used and the follow-up methodology used by each centre.

EVIDENCE SYNTHESIS

More than 2000 anterior urethroplasty procedures have been described in the literature. When considering the bulbar urethra there is no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 mo in 934 and 563 patients, respectively. The lateral onlay technique has only been described in six patients and has a reported success rate of 83% at 77 mo. The Asopa and Palminteri techniques have been described in 89 and 53 patients with a success rate of 86.7% and 90.1% at 28.9 and 21.9 mo, respectively. When considering penile strictures, the success rate of the two-stage penile technique is significantly better than the one-stage penile technique, 90.5% versus 75.7% as calculated for 129 and 432 patients, respectively, although the follow-up of one-stage procedures was longer at 32.8 mo compared with 22.2 mo.

CONCLUSIONS

There is no evidence in the literature of a difference between one-stage techniques for urethroplasty of the bulbar urethra. The two-stage technique has better reported outcomes than a one-stage approach for penile urethroplasty but has a shorter follow-up.

Urethral Reconstruction Using the Radial Forearm Free Flap: Experience in Oncologic Cases and Gender Reassignment

OBJECTIVES

Urethra reconstruction in men remains a complex problem, particularly in patients who have had previous amputation for penile tumour or who have undergone gender reassignment. Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction.

METHODS

During 1999-2004, nine patients underwent microsurgical reconstruction of the male urethra using the radial forearm fasciocutaneous free flap. Three patients underwent urethral reconstruction following previous subcutaneous penectomy for penile cancer. Another six patients had urethral reconstruction performed after failure of primary urethra construction as part of their gender reassignment surgery.

RESULTS

The average age at the time of surgery was 35.1 yr (range: 22-55 yr) and average follow-up time was 41.8 mo (range: 13-55 mo). Flap reconstruction was successful in all cases, with no instances of free flap failure; however, two patients developed significant stenosis requiring revision, and no patients had postoperative fistula formation. Therefore, the success rate for urethral reconstruction after the first operation was seven of nine. Two patients with stenosis were treated operatively to release strictures with local flaps. Uroflowmetry demonstrated that these patients had satisfactory flow rates.

CONCLUSION

Patient satisfaction and objective studies have demonstrated that urethral reconstruction with the use of radial forearm free flap is a good reconstructive procedure particularly when the patients need an extensive and long urethral reconstruction.

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.

Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection

OBJECTIVES

We evaluated the applications and outcomes of substitution urethroplasty, using a variety of techniques, in 65 patients with complex, long-segment urethral strictures.

METHODS

From January 1995 to December 2005, 65 patients with complex urethral strictures >8cm in length underwent substitution urethroplasty. Of the 65 patients, 43 underwent one-stage urethral reconstruction using mucosal grafts (28 colonic mucosal graft, 12 buccal mucosal graft, and 3 bladder mucosal graft), 17 patients underwent one-stage urethroplasty using pedicle flaps, and 5 patients underwent staged Johanson's urethroplasty.

RESULTS

The mean follow-up time was 4.8 yr (range; 0.8-10 yr), with an overall success rate of 76.92% (50 of 65 cases). Complications developed in 15 patients (23.08%) and included recurrent stricture in 7 (10.77%), urethrocutaneous fistula in 3 (4.62%), coloabdominal fistula in 1 (1.54%), penile chordee in 2 (3.08%), and urethral pseudodiverticulum in 2 (3.08%). Recurrent strictures and urethral pseudodiverticulum were treated successfully with a subsequent procedure, including repeat urethroplasty in six cases and urethrotomy or dilation in three. Coloabdominal fistula was corrected only by dressing change; five patients await further reconstruction.

CONCLUSIONS

Penile skin, colonic mucosal, and buccal mucosal grafts are excellent materials for substitution urethroplasty. Colonic mucosal graft urethroplasty is a feasible procedure for complicated urethral strictures involving the entire or multiple portions of the urethra and the technique may also be considered for urethral reconstruction in patients in whom other conventional procedures failed.