Interview with Dr Guido Barbagli Substitution Urethroplasty: Which Tissues and Techniques are Optimal for Urethral Replacement?

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.

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.

A comparative study of lingual mucosal graft urethroplasty with buccal mucosal graft urethroplasty in urethral stricture disease: An institutional experience

AIMS

A prospective study to compare the outcomes of lingual versus buccal mucosal graft urethroplasty in patients with long segment anterior urethral strictures disease.

MATERIALS AND METHODS

The study included 30 patients for buccal mucosal graft urethroplasty (group I) and 30 patients for lingual mucosal graft urethroplasty (group II) for treatment of long segment (>3 cm) incomplete anterior urethral stricture disease using single-stage dorsal onlay free oral mucosal graft urethroplasty by Barbagli's technique between February 2013 to September 2014. All patients underwent complete evaluation of the stricture including inspection of the oral cavity.

RESULTS

The results of urethroplasty in between two group were not significant (P > 0.05) in terms of Qmax (P = 0.63), mean postoperative AUA symptom score (P = 0.83), operative time (P = 0.302) intra operative blood loss (P = 0.708), duration of postoperative hospitalization (P = 0.83), but slurring of speech complications was seen in group II, but not in group I. Long-term complications of salivary disturbance, tightness of the mouth, persistent pain at graft site, perioral numbness, seen only in group I (BMGU).

CONCLUSION

LMG urethroplasty is an excellent alternative to BMG urethroplasty with comparable results of urethroplasty and minimal donor site complications.

Evaluation of the biocompatibility and mechanical properties of naturally derived and synthetic scaffolds for urethral reconstruction

The aim of this study was to evaluate the mechanical properties and biocompatibility of biomaterials, including bladder submucosa (BAMG), small intestinal submucosa (SIS), acellular corpus spongiosum matrix (ACSM), and polyglycolic acid (PGA), to identify the optimal scaffold for urethral tissue engineering. Tensile mechanical testing was conducted to evaluate mechanical properties of each scaffold. Rabbit corporal smooth muscle cells were cultured with the extracts of biomaterials and mitochondrial metabolic activity assay was used to determine the cytotoxicity of scaffold. The pore sizes of each scaffold were measured. Additionally, smooth muscle cells were seeded on biomaterials. Cell infiltration was evaluated. Mechanical evaluation showed that Young modulus, stress at break in ACSM were prior to those in other biomaterials (p < 0.05). MTT assay confirmed that all scaffolds supported normal cellular mitochondrial metabolic without inducing cytotoxic events. SEM demonstrated that PGA has the largest pore size (>200 microm). The ACSM has different pore sizes in urethral (<5 microm) and cavernosal surfaces (>10 microm). Widespread distribution of cells could be observed in PGA 14 days after seeding. Multilayer cellular coverage developed in BAMG and urethral surface of ACSM without any sign of cellular invasion. Moderated cellular penetration could be found in SIS and cavernosal surface of ACSM. Although each scaffold demonstrated suitable mechanical properties, which is similar to normal urethra, ACSM showed better response in some parameters than those in other biomaterials. It suggested that this scaffold may be an alternative for urethral reconstruction in the future. (c) 2010 Wiley Periodicals, Inc. J Biomed Mater Res, 2010.

[Oral mucosa graft urethroplasty for complicated urethral strictures]

OBJECTIVE

We evaluated the efficacy and outcome of one-stage oral mucosa graft urethroplasty, which is currently the procedure of choice for treating lengthy and complicated urethral strictures not amenable to excision and primary end-to-end anastomosis.

PATIENTS AND METHODS

Seven patients 33 to 74 years old (mean age = 53.7) underwent one-stage oral mucosa graft urethroplasty for a stricture in either the bulbar urethra (four patients), penile urethra (two patients), or pan-anterior urethra (one patient). Three of the strictures were due to trauma, one was due to inflammation, and one was due to a failed hypospadia repair. The other two were iatrogenic. All patients had previously undergone either internal urethrotomy or repeated urethral dilation. Three patients received a tube graft, three received a ventral onlay, and one received a dorsal onlay. A free graft of oral mucosa was harvested from the inside of each patient's left cheek, and if necessary to obtain a sufficient length, the harvest was extended to include mucosa from the lower lip and the right cheek. The graft lengths ranged from 2.5 to 12 cm (mean = 4.6 cm). A urethral catheter was left in place for 3 weeks postoperatively.

RESULTS

While no severe complications at the donor site were observed during follow-up periods ranging from 3 to 55 months (mean = 14 months), two patients who had received a tube graft developed distal anastomotic ring strictures that were managed by internal urethrotomy. The other five required no postoperative urological procedure even though one who had received a ventral onlay developed a penoscrotal fistula.

CONCLUSION

Oral mucosa is an ideal urethral graft, and oral mucosa graft urethroplasty is an effective procedure for repairing complicated urethral strictures involving long portions of the urethra.

Augmentation vaginoplasty of colonic neovagina stricture using oral mucosa graft

BACKGROUND

Vaginal reconstruction is performed for a variety of congenital and acquired anomalies, and several techniques have been described. Conventional neovaginal reconstructions typically involve skin grafts or vascularized intestinal segments. Oral mucosa has been used successfully in urethral reconstruction, and several long-term studies have demonstrated its surgical versatility and durability.

CASE REPORT

Here we present the successful use of an oral mucosal graft in the surgical treatment of a strictured, colonic neovagina in a 19-year-old, 46XX female with cloacal exstrophy.

CONCLUSION

Though the literature contains reports of oral mucosal grafts in primary gynecologic surgeries, this is the first report describing the use of buccal mucosa for a secondary, neovagina reconstruction. Based on the outcome of our case, we conclude that oral mucosa is a promising graft material suitable for vaginal reconstructions.

Oral mucosal grafts urethroplasty for the treatment of long segmented anterior urethral strictures

OBJECTIVE

To evaluate the efficacy and safety of using oral mucosal grafts for urethroplasty in the treatment of complex segmented urethral strictures.

METHODS

Between January 2002 and January 2008, 25 cases of long or multi-segmented urethral strictures (10-18 cm, mean 11.72) were treated using combined two oral mucosal graft urethroplasty. Of the 25 patients, combined double buccal mucosal graft (BMG) urethroplasty was performed in nine patients, double lingual mucosal graft (LMG) urethroplasty in seven patients and combined lingual and buccal mucosal graft urethroplasty in nine patients.

RESULTS

Follow-up was obtained for 6-72 months (mean 26.83) post-operatively. Urethrocutaneous fistulas developed in two patients. Urethral strictures developed in one patient undergoing BMG urethroplasty; the patient underwent five urethral dilations, after which he voided well with a urinary peak flow of 26.4 ml/s. Meatal stenosis developed in one patient undergoing LMG and a second operation was required, after which the patient voided well (urinary peak flow of 28.7 ml/s). The other patients voided well and urinary peak flow rates ranged from 16.8 to 49.2 ml/s (mean 28.65 ml/s).

CONCLUSION

Combined two oral mucosal grafts substitution urethroplasty is an effective technique for the treatment of long, segmented urethral strictures.

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.

The use of lingual mucosal graft in adult anterior urethroplasty: surgical steps and short-term outcome

OBJECTIVES

Investigate the tolerability, safety, and efficacy of using the lingual mucosal graft (LMG) for anterior urethroplasty.

METHODS

Ten patients (average age, 41 yr) underwent substitution urethroplasty LMG. Harvesting the graft from the tongue was performed by either the oral surgeon or the urologist. In five patients with penile urethral strictures, the grafts were placed on the dorsal urethral surface as a "dorsal inlay." In five patients with bulbar urethral strictures, the grafts were used as a "dorsal inlay" (3 cases) or "ventral onlay" (2 cases). The average follow-up was 5 mo (range: 3-12 mo).

RESULTS

Nine cases (90%) were successful and one (10%) was a failure. Three patients who underwent bulbar urethroplasty showed prior failed repair using buccal mucosal grafts harvested from a single cheek (1 case), from both cheeks (1 case), or from the lip (1 case). The length of the lingual grafts was 4-6cm (mean: 4.5cm) with a width of 2.5cm. No patient developed early or late postoperative complications on the harvest site related to the tongue surgery. No difference was observed in patients in whom the graft harvesting was performed by the oral surgeon compared to the patients in whom the procedure was performed by the urologist.

CONCLUSIONS

The surgical technique for harvesting a graft from the tongue is simple and safe. The tongue may be the best alternative donor site to the lip when a thin graft is required for urethroplasty or when the cheek harvesting is not possible.