Surgical Techniques in Substitution Urethroplasty Using Buccal Mucosa for the Treatment of Anterior Urethral Strictures

Non-transecting dorsal mucosal anastomosis plus ventral oral graft for the treatment of urethral bulbar strictures: single surgeon experience

PURPOSE

To report our experience with the non-transecting dorsal mucosal anastomosis plus ventral oral graft urethroplasty (NTAVOG) for the repair of tight bulbar urethral strictures.

METHODS

Data of 68 men with tight bulbar strictures underwent NTAVOG urethroplasty between 2012 and 2019 were retrospectively revised. The urethra was opened ventrally; the dorsal scarred mucosa was excised preserving the spongiosum; the mobilized mucosal edges were anastomosed to recreate the dorsal urethral plate; the repaired urethral plate was augmented by the ventral oral graft and the spongiosum was closed over it. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Sexual function was investigated using a validated questionnaire.

RESULTS

Median follow-up was 58 months (IQR 38-63) and mean stricture length was 1 cm (IQR 1-1.5). Of 68 cases, 56 (82.4%) were successful and 12 (17.6%) were failures requiring re-treatment. At multivariable analysis, no preoperative factor was significantly associated with recurrence. None of the preoperatively sexually active 53 patients reported postoperative erectile impairment and all were satisfied with their sexual life. The main limitation is the retrospective design.

CONCLUSIONS

In cases of tight bulbar stricture, the NTAVOG urethroplasty provides adequate urethral augmentation by preserving the spongiosum and avoiding postoperative sexual complications. We presented a series of patients undergone non-transecting dorsal anastomosis plus ventral oral graft urethroplasty for tight bulbar stricture. This treatment seems to be safe and with limited postoperative complications thanks to the preservation of the corpus spongiosum.

Female urethral stricture: which one is stronger? Labial vs buccal graft

INTRODUCTION AND HYPOTHESIS

We aimed to compare labial and buccal mucosa graft methods in female urethroplasty.

METHODS

Female urethroplasty surgeries performed between March 2016 and October 2020 were retrospectively reviewed. Labial and buccal mucosa graft surgeries were listed.

RESULTS

Between March 2016 and October 2020, a total of 28 patients had graft urethroplasty surgery in our center. Fourteen had labial, 14 had buccal onlay graft urethroplasty. The pre-treatment Qmax values were 13 ml/s in the labia major onlay graft (LMOG) group and 12.5 ml/s in the buccal mucosa onlay graft (BMOG) group. The Qmax values after the treatment were remeasured at the 1st, 3rd, and 12th months. They were 20 ml/s, 24 ml/s, and 24 ml/s in the LMOG group and 23 ml/s, 25 ml/s, and 28 ml/s in the BMOG group. The operation times were 65 min (55-90) in the LMOG group; in the BMOG group, it was 70.35 min (65-90).

CONCLUSIONS

In female urethral strictures, especially in long segments and recurrent strictures, graft urethroplasty is a successful and safe method. Dorsal buccal onlay mucosal graft and labia major grafts show similar results in the early period to complications and success. In the long term, buccal onlay mucosal graft gives better results.

Treatment of Meatal Strictures by Dorsal Inlay Oral Mucosa Graft Urethroplasty: A Single-Center Experience

Background: To report on the use of oral mucosa graft urethroplasty for meatal strictures using the dorsal inlay technique. Methods: Patients who underwent a single-stage dorsal inlay oral mucosal graft urethroplasty between January 2000 and May 2021 were included in this study. A follow-up of a minimum of 12 months was necessary for inclusion. Exclusion criteria were stricture extension into the penile urethra, concomitant stricture at another location, flap urethroplasty for a meatal stricture, dorsal inlay urethroplasty with another type of graft, ventral onlay graft urethroplasty or staged urethroplasty. Recurrence was defined by the inability to pass a 14F metal sound through the reconstructed meatus irrespective of patients’ complaints. Results: Our study cohort included 40 patients. Buccal mucosal graft (BMG) urethroplasty was used in 25 patients and 15 patients were treated with the aid of lingual mucosal graft (LMG). The median follow-up was 85 (IQR: 69–110) months. Seven (17.5%) patients suffered a stricture recurrence of which four (10%) needed re-intervention. The median 5-y recurrent free survival (RFS) for the entire cohort was 85 (±6)%. The median 5-y RFS was 96 (±4)% versus 65 (±13)% for respectively BMG and LMG (p = 0.03). Post-operative complications were identified in 11 (27.5%) patients with only one (2.5%) patient who had a grade 3a complication. Conclusions: Dorsal inlay oral mucosa graft urethroplasty is a safe and feasible technique for selected patients with meatal stenosis.

A systematic review and meta-analysis of urethral complications and outcomes in transgender men

BACKGROUND

Urologic problems, such as urethral fistulas and strictures, are among the most frequent complications occurring after phalloplasty. Although many studies have reported successful phalloplasty and urethral reconstruction with reliable outcomes in transgender men, no method has become standardized so far. This study aimed to summarize the results of reports on urological complications and outcomes in transgender men with respect to various types of urethral reconstruction.

METHODS

A comprehensive literature search of PubMed, Scopus, and Google Scholar databases was conducted for studies related to phalloplasty in transsexuals. Data on various phallic urethral techniques, urethral complications, and outcomes were collected and analyzed using the random-effects model.

RESULTS

A total of 21 studies (1,566 patients) were included: eight studies (1,061 patients) on "tube-in-tube," nine studies (273 patients) on "prelaminated flap," and six studies (221 patients) on "second flap." Compared with the tube-in-tube technique, the prelaminated flap was associated with a significantly higher urethral stricture/stenosis rate; however, there was no difference between the prelaminated flap and the second flap techniques. For all phalloplasty patients, the pool rate of urethral fistula or stenosis is 48.9%, the rate of the ability to void while standing is 91.5%, occurrence rate of tactile or erogenous sensation is 88%, the prosthesis complication rate is 27.9%, and patient-reported satisfactory outcome rate is 90.5%.

CONCLUSION

Urethral reconstruction with a prelaminated flap was associated with a significantly higher urethral stricture rate and increased need of revision surgery compared with that observed using a skin flap. Overall, most patients were able to void while standing and were satisfied with the outcomes.

Posteriorly Augmented Anastomotic Ureteroplasty with Lingual Mucosal Onlay Grafts for Long Proximal Ureteral Strictures: 10 Cases of Experience

Objective: To share the technique of posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures as well as our initial experience with the technique. Methods: From October 2018 to September 2019, 10 cases of robotic and laparoscopic posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures were recruited from our database of Reconstruction of Urinary Tract: Technology, Epidemiology and Result (RECUTTER). The perioperative and follow-up data were recorded. Complete success was defined as the absence of clinical symptoms, relieved stenosis on imaging, and a stable estimated glomerular filtration rate without serious complications. Results: All surgeries were completed without serious complications. There were eight laparoscopic surgeries and two robotic surgeries. The median length of defect after posteriorly augmented anastomosis was 3 cm (range, 3-5 cm). The median length of the lingual mucosa graft was 4 cm (range, 3-5 cm). The median operative time was 237 minutes (range, 189-310 minutes). The median estimated blood loss was 40 mL (range, 10-100 mL). The median postoperative length of stay was 7.5 days (range, 5-22 days). The Double-J stent was removed median 3.5 months (range, 2-7 months) after the surgery. At the median follow-up of 11 months (range, 7-20 months), all patients achieved the successful criteria of treatment. Conclusion: The posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures is a feasible and safe technique, which may be an option especially for strictures marginally longer than those that can be safely repaired via end-to-end anastomosis.

Laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures: our experience and strategy

PURPOSE

To present our experience of laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures and summarize our treatment strategies for these challenging scenarios.

METHODS

From March 2018 to January 2020, 53 patients with long proximal/middle ureteral strictures (2-6 cm) who underwent laparoscopic or robotic onlay flap/graft ureteroplasty were retrospectively enrolled. Different reconstruction techniques were chosen based on our management strategy: pelvic flap (PF) was the first choice for proximal stricture if pelvic tissue was sufficient for repair, while appendiceal flap (AF) was preferred over oral mucosa graft for both proximal and middle strictures.

RESULTS

A total of 28 PFs, 9 AFs and 16 lingual mucosa grafts (LMGs) onlay ureteroplasty were performed successfully, with 33 laparoscopic procedures and 20 robotic procedures being undertaken. No intraoperative complications or conversion occurred. The median stricture length was 4 cm (range 2-6 cm). Compared with laparoscopic procedures, robotic procedures showed significantly shorter operative time (P = 0.008), shorter postoperative hospital stay (P = 0.011) but higher hospital cost (P < 0.001). At a mean follow-up of 12.8 months, the overall success rate was 94.3%. There was no difference in postoperative complications or the success rate between the approaches.

CONCLUSION

Laparoscopic and robotic onlay flap/graft ureteroplasty can be safe and feasible to repair long proximal/middle ureteral strictures while robotic procedures showed higher efficiency, faster recovery but higher cost. Our algorithmic strategies may provide beneficial references for their standardization and dissemination into clinical care.

Patient-reported outcomes for typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting: a single-center analysis of more than 800 patients

PURPOSE

The optimal harvesting site for oral grafting in patients with urethral strictures remain controversial, with no study investigating morbidity on large scale. We aimed to compare typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting in terms of complications and patient-reported outcomes.

METHODS

Within 827 patients treated at our referral center with oral graft urethroplasty, we compared typical vs atypical harvesting techniques. A self-administered, semiquantitative, non-validated questionnaire assessed early (10 days) and late (4 months) postoperative complications and patient-reported outcomes. A semiquantitative score was calculated according to patient responses, and it was used to assess early (6 questions) and late (13 questions) patient dissatisfaction status. Patients were defined early and/or late dissatisfied when they scored ≥ 7 and ≥ 10 at the early or late questionnaires, respectively.

RESULTS

Between 1998 and 2019, our patients predominantly received typical single cheek harvesting (89% vs 11%), with + 1.5% increase rate per year (p < 0.001). Early and late dissatisfied patients were, respectively, 170 (23%) vs 39 (44%) and 59 (8%) vs 16 (18%) in the typical vs atypical groups. Atypical harvesting was associated with higher rates of early (Odds ratio [OR]: 2.34; 95% Confidence interval [CI] 1.44-3.75; p = 0.001) and late (OR: 2.37; 95%CI 1.22-4.42; p = 0.008) postoperative dissatisfaction.

CONCLUSIONS

Typical single cheek harvesting was the preferred surgical option at our center and it was associated with negligible early and late rates of complications and patient's dissatisfaction. Conversely, atypical lingual, labial or bilateral cheeks harvesting was associated with higher complications and frequent patient dissatisfaction.

Tubularized urethral reconstruction using a prevascularized capsular tissue prelaminated with buccal mucosa graft in a rabbit model

Tubularized graft urethroplasty fails largely because of inadequate graft take. Prefabrication of buccal mucosa lined flap has theoretical indications for constructing neourethra with an independent blood supply. The efficacy of using a tissue expander capsule as an induced vascular bed to prefabricate an axial vascularized buccal mucosa-lined flap for tubularized urethral reconstruction in a rabbit model was tested. The experiments were performed in three stages. First, silicone tissue expanders were inserted into the groin to induce vascularized capsule pouch formation. Next, buccal mucosa grafts were transplanted to the newly formed capsular tissue supplied by the axial vessel for buccal mucosa-lined flap prefabrication. Then, circumferential urethral defects were created and repaired by buccal mucosa graft (Group 1), capsule flap (Group 2) and prefabricated capsule buccal mucosa composite flap (Group 3). With retrograde urethrography, no rabbits in Group 1 maintained a wide urethral caliber. In Group 2, the discontinued epithelial layer regenerated at 1 month, and the constructed neourethra narrowed even though the lumen surface formed intact urothelial cells at 3 months. In Group 3, buccal mucosa formed the lining in the neourethra and kept a wide urethral caliber for 3 months. The capsule may serve as an induced vascular bed for buccal mucosa-lined flap prefabrication. The prefabricated buccal mucosa-lined flap may serve as a neourethra flap for circumferential urethral replacement.

Outcome of staged buccal mucosal graft for repair of long segment anterior urethral stricture

Background

Long anterior urethral stricture due to variable etiological factors constitutes a challenge for reconstruction.

We evaluated our centers experience with cases of long anterior urethral stricture due to different etiologies that were managed by 2-stage substitution urethroplasty using buccal mucosal graft procedure.

Methods

During the period between November 2009 and November 2016. All cases with long anterior urethral stricture that were planned for substitution urethroplasty in our department were enrolled in this study. The first stage was excision of most fibrotic areas of the urethral plate, the remaining of the urethra is laid open and augmented with buccal mucosal graft for second stage closure after 6–9 months.

Results

The study included 123 patients who underwent first stage, 105 patients of them underwent second stage urethroplasty. Eighteen cases were missed after first stage. The mean (range) age was 38.4 (17–60 years). The mean (range) stricture length was 8.3 (4–13 cm). The cause of stricture was idiopathic in 47, inflammatory in 15, lichen sclerosus in 26 and post failed hypospadias repair in 35 patients. First stage was complicated by graft contracture in 11 (8.9%) patients that needed re-grafting, 5(4.1%) patient had bleeding from the buccal mucosa site that needed haemostatic sutures, oral numbness was reported in 7 (5.7%) patients. Second stage was complicated by wound dehiscence in 2(1.9%) patients, restricture in 11 (10.5%), fistula in 6 (5.7%) patients, meatal stenosis in 3 (2.9%). The overall success rate was 79.1% (83 cases out of 105) with a mean (range) follow-up of 34.7 (10–58 months).

Conclusions

Staged urethroplasty using buccal mucosal graft procedure is an effective surgical option for patients with long anterior urethral strictures especially for patients with lichen sclerosus and those with failed previous surgical repair.

Dorsal versus ventral strip augmented anastomotic bulbar urethroplasty: retrospective study

PURPOSE

The published literature shows controversies with regard to the treatment of choice for longer stricture. Augmented anastomotic urethroplasty (AAU) was described for long bulbar urethral strictures with an extended area of narrowing and fibrosis, the technique combines the advantages of both anastomosis and graft substitution. We aimed to compare the dorsal and ventral strip anastomosis in the AAU.

METHODS

A retrospective Review was conducted at the Department of Urology, Sohag University Hospital; we included adult patients with long bulbar urethral strictures (> 2 cm) who underwent dorsal or ventral strip AAU. Patients were followed at 1, 3, 6, and 12 months postoperatively for subjective improvements. The statistical analysis was carried with SPSS software version 24 for windows.

RESULTS

At the end of follow-up, stricture recurrence occurred in 5 (12.5%) in ventral strip group compared to 6 (23.1%) in dorsal group, the difference was not statistically significant (p = 0.5). With regard to safety outcomes, there was no statistically significant difference between both groups in any of the postoperative complications, except post-void dribbling which showed higher incidence in dorsal strip group (p < 0.001).

CONCLUSIONS

In conclusion, both dorsal strip and ventral strip techniques are feasible for long bulbar urethral strictures with comparable postoperative efficacy outcomes and high success rate.

Overcoming scarring in the urethra: Challenges for tissue engineering

Urethral stricture disease is increasingly common occurring in about 1% of males over the age of 55. The stricture tissue is rich in myofibroblasts and multi-nucleated giant cells which are thought to be related to stricture formation and collagen synthesis. An increase in collagen is associated with the loss of the normal vasculature of the normal urethra. The actual incidence differs based on worldwide populations, geography, and income. The stricture aetiology, location, length and patient's age and comorbidity are important in deciding the course of treatment. In this review we aim to summarise the existing knowledge of the aetiology of urethral strictures, review current treatment regimens, and present the challenges of using tissue-engineered buccal mucosa (TEBM) to repair scarring of the urethra. In asking this question we are also mindful that recurrent fibrosis occurs in other tissues-how can we learn from these other pathologies?

Two-Stage Urethroplasty with Buccal Mucosa for Penoscrotal Hypospadias Reconstruction in a Male with a 46,XX Karyotype

We present a case regarding a 32-year old African male with penoscrotal hypospadias, left cryptorchidism and a left inguinal hernia. There were moderate masculinization characteristics. He underwent a Lichtenstein hernia repair with perioperative biopsies of the left inguinal testis and epididymis. Microscopic examination showed a Sertoli-only left testis with Leydig-cell hyperplasia and the left epididymis consisted of ovarian tissue with corpora albicantia and maturing follicles. Endocrinological evaluation showed a sex-determining region Y (SRY) negative 46,XX karyotype. We successfully performed a two-stage urethroplasty with buccal mucosa graft to reconstruct his penoscrotal hypospadias.

Fabrication of Tissue-Engineered Bionic Urethra Using Cell Sheet Technology and Labeling By Ultrasmall Superparamagnetic Iron Oxide for Full-Thickness Urethral Reconstruction

Urethral strictures remain a reconstructive challenge, due to less than satisfactory outcomes and high incidence of stricture recurrence. An “ideal” urethral reconstruction should establish similar architecture and function as the original urethral wall. We fabricated a novel tissue-engineered bionic urethras using cell sheet technology and report their viability in a canine model. Small amounts of oral and adipose tissues were harvested, and adipose-derived stem cells, oral mucosal epithelial cells, and oral mucosal fibroblasts were isolated and used to prepare cell sheets. The cell sheets were hierarchically tubularized to form 3-layer tissue-engineered urethras and labeled by ultrasmall super-paramagnetic iron oxide (USPIO). The constructed tissue-engineered urethras were transplanted subcutaneously for 3 weeks to promote the revascularization and biomechanical strength of the implant. Then, 2 cm length of the tubularized penile urethra was replaced by tissue-engineered bionic urethra. At 3 months of urethral replacement, USPIO-labeled tissue-engineered bionic urethra can be effectively detected by MRI at the transplant site. Histologically, the retrieved bionic urethras still displayed 3 layers, including an epithelial layer, a fibrous layer, and a myoblast layer. Three weeks after subcutaneous transplantation, immunofluorescence analysis showed the density of blood vessels in bionic urethra was significantly increased following the initial establishment of the constructs and was further up-regulated at 3 months after urethral replacement and was close to normal level in urethral tissue. Our study is the first to experimentally demonstrate 3-layer tissue-engineered urethras can be established using cell sheet technology and can promote the regeneration of structural and functional urethras similar to normal urethra.

Intermediate-Term Outcomes and Complications of Long Segment Urethroplasty with Lingual Mucosa Grafts

PURPOSE

We evaluated outcomes and donor site complications in male patients with complex urethral strictures who underwent urethroplasty using with long strip oral mucosal grafts. We also analyzed whether a lingual mucosa graft is a good substitute for repairing long segment urethral strictures.

MATERIALS AND METHODS

This retrospective study was done in 81 male patients with complex urethral strictures who underwent oral mucosal graft urethroplasty. Patients with long segment (8 cm or greater) anterior urethral strictures who were considered candidates for long strip lingual mucosa graft urethroplasty were included in study.

RESULTS

Oral mucosal graft urethroplasty was performed in 81 patients with complex urethral strictures between August 2006 and December 2014. Mean urethral stricture length was 12.1 cm (range 8 to 20). A single 9 to 12 cm long strip lingual mucosa graft was used in 52 patients, a lingual mucosa graft greater than 12 cm was placed in 17 and a lingual mucosa graft combined with a buccal mucosal graft was used in 12. Mean followup was 41 months (range 15 to 86) postoperatively. The overall urethroplasty success rate was 82.7%. Urethral complications developed in 14 patients (17.3%), including urethral strictures in 10 and urethrocutaneous fistulas in 4. At 12 months 5 patients (6.2%) reported minimal difficulty with fine motor movement of the tongue.

CONCLUSIONS

Lingual mucosa harvested from the ventrolateral surface of the tongue can provide a wide and long graft that is an excellent urethral substitute. Donor site complications are primarily limited to postoperative year 1. Our study confirms that the lingual mucosa graft is a good substitute for urethral reconstruction and lingual mucosa graft urethroplasty is a valuable procedure to treat long anterior urethral strictures.

Total proximal ureter substitution using buccal mucosa

The surgical treatment of a long proximal ureteral stricture is a challenging situation for reconstructive surgeons. Despite the underlying morbidities, ileal interposition and autotransplantation are the options available to treat complex cases of long segment ureteral stricture. Buccal mucosa has shown excellent results in urethroplasty. However, its use in ureteral reconstruction is infrequent. We report on a 64-year-old female patient with multiple comorbidities and prior abdominal surgeries for Crohn's disease who underwent a successful total substitution of a long segment of the proximal ureter using buccal mucosa. Regular postoperative isotope scans showed improvement in renal function. Based on the pleasant outcome of this case and review of the literature, buccal mucosa might be a viable option with low morbidity in selected cases.

Graft Use in Bulbar Urethroplasty

The gold standard for bulbar urethroplasty has been excision and primary anastomosis. Application of this approach is generally limited to strictures that are 2 cm or less in the bulbar urethra due to penile shortening. Strictures greater than 2 cm are successfully treated with augmentation urethroplasty wherein the narrowed segment is not excised but widened with the use of a skin flap or a tissue graft. Buccal mucosa is the most prevalent tissue for bulbar urethral stricture repair for strictures greater than 2 cm. Outcomes for the different graft locations are similar, approximately 90%.

Single stage: dorsolateral onlay buccal mucosal urethroplasty for long anterior urethral strictures using perineal route

Objective

To assess the outcome of single stage dorsolateral onlay buccal mucosal urethroplasty for long anterior urethral strictures (>4cm long) using a perineal incision.

Materials and Methods

From August 2010 to August 2013, 20 patients underwent BMG urethroplasty. The cause of stricture was Lichen sclerosis in 12 cases (60%), Instrumentation in 5 cases (25%), and unknown in 3 cases (15%). Strictures were approached through a perineal skin incision and penis was invaginated into it to access the entire urethra. All the grafts were placed dorsolaterally, preserving the bulbospongiosus muscle, central tendon of perineum and one-sided attachement of corpus spongiosum. Procedure was considered to be failure if the patient required instrumentation postoperatively.

Results

Mean stricture length was 8.5cm (range 4 to 12cm). Mean follow-up was 22.7 months (range 12 to 36 months). Overall success rate was 85%. There were 3 failures (meatal stenosis in 1, proximal stricture in 1 and whole length recurrent stricture in 1). Other complications included wound infection, urethrocutaneous fistula, brownish discharge per urethra and scrotal oedema.

Conclusion

Dorsolateral buccal mucosal urethroplasty for long anterior urethral strictures using a single perineal incision is simple, safe and easily reproducible by urologists with a good outcome.

[URETHROPLASTY FOR COMPLICATED ANTERIOR URETHRAL STRICTURES]

(Objectives) To compare efficacy and outcome of urethroplasty for complicated anterior urethral strictures. (Methods) Twelve patients, included 3 boys, with anterior urethral stricture underwent urethroplasty after the failure of either urethral dilatation or internal urethrotomy. We evaluated pre- and post-operative Q max and surgical outcome. (Results) Four patients were treated with end-to-end anastomosis, included a case of bulbar urethral elongation simultaneously, one patient was treated with augmented anastomotic urethroplasty, three patients were treated with onlay urethroplasty with prepucial flap, one patient was treated with tubed urethroplasty with prepucial flap (Ducket procedure) and three patients were treated with onlay urethroplasty with buccal mucosal graft. Postoperative Qmax improved in all patients without major complications and recurrence during follow-up periods ranging from 17 to 102 months (mean 55 months). (Conclusions) Urethroplasty is an effective therapeutic procedure for complicated anterior urethral stricture.

Management of Long-Segment and Panurethral Stricture Disease

Long-segment urethral stricture or panurethral stricture disease, involving the different anatomic segments of anterior urethra, is a relatively less common lesion of the anterior urethra compared to bulbar stricture. However, it is a particularly difficult surgical challenge for the reconstructive urologist. The etiology varies according to age and geographic location, lichen sclerosus being the most prevalent in some regions of the globe. Other common and significant causes are previous endoscopic urethral manipulations (urethral catheterization, cystourethroscopy, and transurethral resection), previous urethral surgery, trauma, inflammation, and idiopathic. The iatrogenic causes are the most predominant in the Western or industrialized countries, and lichen sclerosus is the most common in India. Several surgical procedures and their modifications, including those performed in one or more stages and with the use of adjunct tissue transfer maneuvers, have been developed and used worldwide, with varying long-term success. A one-stage, minimally invasive technique approached through a single perineal incision has gained widespread popularity for its effectiveness and reproducibility. Nonetheless, for a successful result, the reconstructive urologist should be experienced and familiar with the different treatment modalities currently available and select the best procedure for the individual patient.

Surgical Repair of Bulbar Urethral Strictures: Advantages of Ventral, Dorsal, and Lateral Approaches and When to Choose Them

Objectives. To review the available literature describing the three most common approaches for buccal mucosal graft (BMG) augmentation during reconstruction of bulbar urethral strictures. Due to its excellent histological properties, buccal mucosa graft is now routinely used in urethral reconstruction. The best approach for the placement of such a graft remains controversial. Methods. PubMed search was conducted for available English literature describing outcomes of bulbar urethroplasty augmentation techniques using dorsal, ventral, and lateral approaches. Prospective and retrospective studies as well as meta-analyses and latest systematic reviews were included. Results. Most of the studies reviewed are of retrospective nature and majority described dorsal or ventral approaches. Medium- and long-term outcomes of all three approaches were comparable ranging between 80 and 88%. Conclusion. Various techniques of BMG augmentation urethroplasty have been described for repairs of bulbar urethral strictures. In this review, we describe and compare the three most common “competing” approaches for bulbar urethroplasty with utilization of BMG.

Orandi flap for penile urethral stricture: Polishing the gold standard

INTRODUCTION

We describe the combined use of the Orandi flap and the scrotal skin advancement flap to reduce complications for pendulous urethral stricture in men >40 years old.

METHODS

Over the last 40 months, 10 men underwent urethroplasty for pendulous stricture by the modified Orandi urethroplasty. In this, additionally, a midline hairless scrotal skin flap of the size of the ventral skin defect on the pendulous portion was raised based on the dartos fascia. This flap was mobilized so that it reached the pendulous portion without tension and covered the penile defect. The catheter was removed after 4 weeks. Patients were followed every 3 months using uroflowmetry and the American Urological Association (AUA) symptom score.

RESULTS

The mean age was 55.5. Of the 10 patients, the etiology was post-catheterization in 5 and idiopathic in the remaining 5. Three men also had stricture extending into the bulbous urethra (repaired using buccal graft). The mean additional time needed for the flap coverage was 36.2 minutes (range: 30-45). The median follow-up was 12 months (range: 3-40). The mean postoperative symptom score was 5.2 and the mean flow rate was 20.1 mL/sec. In 2 men, the meatus got retracted to the distal penile part (probably due to downward traction by scrotal skin). No patient complained of disfigurement. Two men reported recurrence (1 each in bulbous and penile urethra). The limitations are small number of patients and the observational nature of this study.

CONCLUSIONS

The intermediate-term results show that the modified Orandi urethroplasty is an acceptable treatment option with acceptable cosmetic results.

Patient-Reported Sexual Function After Staged Penile Urethroplasty

OBJECTIVE

To evaluate sexual function after staged penile urethroplasty with oral mucosal graft (OMG).

METHODS

We identified men with completed staged penile urethroplasty with OMG from the Trauma and Urologic Reconstruction Network of Surgeons database between January 1, 2010 and May 1, 2014. Our primary outcome was change in total Sexual Health Inventory for Men (SHIM) and total Male Sexual Health Questionnaire Ejaculatory Domain (MSHQ-EjD) Short Form at baseline vs after the second stage of the procedure. Second, we assessed subjective changes in penile curvature, length, and sensation.

RESULTS

Thirty-three patients were included with a mean age of 45 years and mean body mass index of 27.6 kg/m(2). Urethral strictures arose from failed hypospadias repair in 52% and lichen sclerosus in 27%. Fifty-two percent of patients reported a previous urethroplasty. The median follow-up time between the second stage procedure and postoperative questionnaires was 6.3 months (interquartile range: 3.5-13.3). There was no significant change in the total SHIM (Δ0.64, 95% confidence interval [CI]: -3.00∼1.72) and MSHQ-EjD (Δ1.55, 95% CI: -1.53∼4.63) scores preoperatively vs postoperatively. In addition, 32% reported improved and 52% no change in satisfaction with sexual intercourse (SHIM Q5). Forty percent of patients reported reduced and 45% no change in bother with ejaculation after surgery (MSHQ-EjD Q4). Men reported new penile curvature (23%), loss of penile length (55%), and altered penile sensitivity (45%) after surgery.

CONCLUSION

Patients undergoing staged penile urethroplasty with OMG are likely to have minimal changes in erectile and ejaculatory function postoperatively, although many may experience new penile curvature, reduced penile length, and/or reduced penile sensitivity.

Buccal mucosa urethroplasty: a 10-year retrospective review of maxillofacial and urological outcomes

BACKGROUND

Reconstruction of a urethral stricture poses a difficult surgical problem. Anastomotic repair remains the gold standard. Strictures longer than 2 cm may require substitution urethroplasty. This is a retrospective review of all patients who underwent urethral reconstruction with an autologous free buccal mucosa graft at a Regional hospital between 1998 and 2009.

METHODS

Variables recorded included; demographics: patient gender/age; follow-up period. Urology: pre-operative diagnosis/aetiology; presenting complaint; previous urological surgery, pre-operative retrograde urethrogram, stricture length, graft size, operative time/blood loss, morbidity, complications. Maxillofacial: pre-/post-operative inter-incisal opening, patency of Stenson's parotid duct, ipsilateral parotid swelling, sensory nerve deficit.

RESULTS

A total of eight male patients were included. Mean age was 33 years. Two patients had one-stage dorsal onlay urethroplasty, and the remaining six had a two-stage BMG urethroplasty. All patients underwent a urethrogram 20 days post-operatively, which demonstrated no leak, and a good caliber grafted urethra in all cases. A flexible cystoscopy scope was accommodated in all patients 8 weeks post-operatively. Mean follow-up was 42 months. At long-term follow-up, there was no evidence of stricture formation, and all patients were voiding well. There were no long-term intra-oral complications.

CONCLUSION

This study suggests that anterior urethral strictures up to 6 cm in length may be predictably and safely managed with buccal mucosal urethroplasty. The buccal mucosa is easy to harvest, and can be used successfully in one- and two-stage grafting procedures. The rate of complications, from both a urological and maxillofacial perspective, in the group of patients studied was low.

Outcomes of dorsal and ventral buccal graft urethroplasty at a tertiary hospital in Uganda

Purpose. Although the use of buccal mucosa in substitution urethroplasty has been practiced for some years, it has not been free of controversy over which surgical technique is the most appropriate to use. There is paucity of data in Sub-Saharan Africa about its success; this study presents the outcomes of dorsal and ventral buccal graft urethroplasty at a sub-Saharan tertiary hospital. Methods. This is a prospective study in which buccal mucosa was used for ventral and dorsal grafts; followup was up to two years. All patients provided informed written consent for the procedures. Results. Seventy-two patients with bulbar urethral strictures underwent buccal graft one-stage urethroplasty. Mean age was 55 years; etiology of the strictures was postinflammatory due to urethritis from sexually transmitted infections 97% (70/72) and trauma 3% (2/72). Buccal mucosa grafts were harvested from the cheek using a two-team approach. Grafts were placed on the ventral and dorsal urethral surfaces in 32 and 40 cases, respectively; the success rate was 84 and 80%, respectively. Repeated urethroplasty was successfully done among 10% (7/72) and patients reported resolution of symptoms in the follow-up period. Conclusion. There was no difference between dorsal and ventral onlay buccal graft outcomes for bulbar urethral strictures. The success rate was 80 to 84%.

Combined Dorsal Plus Ventral Double-Graft Urethroplasty in Anterior Urethral Reconstruction

This study aims to investigate the effect of combined dorsal plus ventral double-graft urethroplasty in anterior urethral reconstruction. Patients who underwent graft urethroplasty for anterior urethral strictures at West China Hospital from 2005 to 2010 were followed up with clinical evaluation. According to the site of graft fixed, patients were divided into single-onlay group (dorsal or ventral) and double-onlay group (dorsal plus ventral). Success rate and complications were compared between the two groups and were analyzed using t test and chi-square. A total of 77 patients completed the follow-up, 51 in single-onlay group and 26 in double group. There was no statistical difference in terms of age, length, site, stricture reason, and the type of graft used between the two groups. The mean follow-up time was 15.6 months (range from 4 to 33 months) in double group and 39.5 months (range from 15 to 59 months) in single group. The total success rate was 72.5 % in single-onlay group and 88.5 % in double-onlay group; no statistical difference existed (p > 0.05). Subgroup analysis shows the success rate was higher for double-onlay urethroplasty for the stricture of penoscrotal junction (88.9 vs 60.9 %, p < 0.05). The main postoperative complications including infection and urethrocutaneous fistula were not significant between the two groups (p > 0.05). Combined dorsal plus ventral double-graft urethroplasty showed a high success and low complication rate for anterior urethral strictures, especially for the penoscrotal junction.

Tissue-engineered buccal mucosa using silk fibroin matrices for urethral reconstruction in a canine model

BACKGROUND

To investigate the feasibility of urethral reconstruction using tissue-engineered buccal mucosa (TEBM) with silk fibroin (SF) matrices in a canine model.

MATERIALS AND METHODS

Autologous oral keratinocytes and autologous fibroblasts were isolated, expanded, and seeded onto SF matrices to obtain TEBM. The TEBM was assessed using hematoxylin and eosin staining and scanning electron microscopy. A 5-cm urethral mucosal defect was created in 10 female canines. Urethroplasty was performed using TEBM in five canines in the experimental group and with SF matrices without cells in the five canines in the comparison group. Retrograde urethrography was performed after 6 mo of grafting. The urethral grafts were analyzed grossly and histologically.

RESULTS

The oral keratinocytes and fibroblasts exhibited good biocompatibility with the SF matrices. TEBM could be constructed using SF matrices. The canines implanted with the tissue-engineered mucosa voided without difficulty. The retrograde urethrography revealed no sign of stricture. The histologic staining showed that epithelial cells developed gradually and exhibited stratified epithelial layers at 6 mo. In the comparison group, the canines had difficulty voiding, and the retrograde urethrography showed urethra stricture. The histologic staining showed that one to two layers of epithelial cells developed.

CONCLUSIONS

The TEBM using SF matrices could be a potential material for urethra reconstruction.

Single stage ventral onlay buccal mucosal graft urethroplasty for navicular fossa strictures

INTRODUCTION

The correction of fossa navicularis strictures poses a distinct reconstructive challenge as it requires attention to cosmesis, in addition to urethral patency. Different graft and flap based repairs have been described with variable success rates. However, the ideal management remains unclear. The feasibility and efficacy of a single stage ventral onlay buccal mucosa graft urethroplasty (VOBMGU) for navicular fossa strictures (NFS) was evaluated in the present study.

SUBJECTS AND METHODS

All patients with NFS attending urology out-patient department from March, 2009 onward accepting VOBMGU were evaluated prospectively. Patients with minimum 1 year of follow-up were included for analysis. The technique involves opening the diseased stenosed meatus ventrally up to the corona. The diseased mucosa is excised leaving a midline strip of native urethral mucosa on the dorsal side. The buccal mucosal graft (BMG) is fixed on either side of this strip over a 24 Fr. silicone catheter. The glans wings are apposed in midline taking anchoring bites on the mucosal graft ventrally. Post-operatively patients were reviewed at 1, 3, 6 and 12 months and annually thereafter. Cosmetic acceptance and splaying of the urinary stream was assessed with individual questionnaires.

RESULTS

A total of six patients underwent VOBMGU. Average flow rate at 3 months post-operatively was 12 ml/s. The end result was cosmetically highly acceptable. There was no fistula in any of the cases. With a median follow-up of 37 months, only one patient had a recurrence of stricture in a proximal site.

CONCLUSIONS

VOBMGU is a viable technique for reconstruction of NFS with promising short term results. However, long-term follow-up is necessary.

Male urethral strictures and their management

Male urethral stricture disease is prevalent and has a substantial impact on quality of life and health-care costs. Management of urethral strictures is complex and depends on the characteristics of the stricture. Data show that there is no difference between urethral dilation and internal urethrotomy in terms of long-term outcomes; success rates range widely from 8-80%, with long-term success rates of 20-30%. For both of these procedures, the risk of recurrence is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures. Analysis has shown that repeated use of urethrotomy is not clinically effective or cost-effective in these patients. Long-term success rates are higher for surgical reconstruction with urethroplasty, with most studies showing success rates of 85-90%. Many techniques have been utilized for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.

The advantages of the ventral approach to bulbar urethroplasty

BACKGROUND

Several surgical techniques have been described for the treatment of bulbar urethral strictures, and the main goal of modern surgery is to reduce morbidity and obtain the best outcome with the fewest complications. Currently, the superiority of one surgical technique over another has not yet been clearly defined.

METHODS

We analysed the historical background, advantages and disadvantages of several urethral approaches and graft placements, with the aim of focusing on the advantages of the ventral approach.

CONCLUSIONS

For short bulbar strictures (<2 cm) the traditionally advocated method is excision and end-to-end anastomosis, whilst for longer strictures, in the last decade, the patch graft urethroplasty has been used, with buccal mucosa advocated as the standard material of substitution. Our analysis showed that the approach (dorsal vs. ventral) to the bulbar urethral lumen and the location of the patch (dorsal vs. ventral) are contentious issues. Overall, surgeons tend to use techniques that are easy, quick and give excellent outcomes with few complications. The graft urethroplasty using the ventral approach fulfils these requirements.

Preconstruction of the Pars Pendulans Urethrae for Phalloplasty with Digestive Mucosa Using a Prefabricated Anterolateral Thigh Flap in a One-arm Patient

Summary:

We herein report a successful preconstruction of the pars pendulans urethrae with the ileum mucosa for phalloplasty in a one-arm patient using a prefabricated anterolateral thigh flap. After a 2-stage operation and an 18-month follow-up, the patient achieved a good postoperative appearance and an excellent function of neophallus. We believe the use of digestive mucosa for urethral reconstruction enlightens us and deserves further comprehensive clinical studies.

Current management of urethral stricture

The surgical treatment of urethral stricture diseases is continually evolving. Although various surgical techniques are available for the treatment of anterior urethral stricture, no one technique has been identified as the method of choice. This article provides a brief updated review of the surgical options for the management of different sites and different types of anterior urethral stricture. This review also covers present controversies in urethral reconstruction. Among the various procedures available for treating urethral stricture, one-stage buccal mucosal graft urethroplasty is currently widely used. The choice of technique for urethroplasty for an individual case largely depends on the expertise of the surgeon. Therefore, urologists working in this field should keep themselves updated on the numerous surgical techniques to deal with any condition of the urethra that might surface at the time of surgery.

[Causes and salvage of failed urethroplasties for traumatic urethral injury]

OBJECTIVES

Salvage urethroplasty after failed repair of traumatic urethral injury is a urological challenge, and we herein describe our experience with it.

METHODS

From October 2010 to January 2012, five patients underwent salvage repair of failed urethroplasties for traumatic urethral injuries: three bulbar straddle injuries and two pelvic fracture urethral injuries. One of the three failed urethroplasties for bulbar straddle injuries was a stricture excision and primary anastomosis, and its failure was due to periurethral abscess formation. Another was an augmented anastomotic urethroplasty using buccal mucosa, and its failure was due to periurethral abscess formation. The third was a tube graft urethroplasty using buccal mucosa, and its failure was due to a stricture at the anastomotic site. Two failed urethroplasties for pelvic fracture urethral injuries were perineal anastomotic repairs combined with corporal separation and inferior pubectomy, and the failures of both were due to ischemic bulbar necrosis. The urethral gap lengths estimated from urethrograms ranged from 12 to 45 mm (mean = 26 mm).

RESULTS

Urethroplasties in all patients with bulbar straddle injuries were salvaged by stricture excision and primary anastomosis with corporal separation, and urethroplasties in both patients with pelvic fracture urethral injuries were salvaged by abdominal transpubic perineal urethroplasty. Although the patients who underwent transpubic urethroplasty had transient pelvic girdle pain, no severe complications were observed. All patients were for 10 to 25 months postoperatively (mean = 16 months) able to void satisfactorily without additional treatment.

CONCLUSIONS

Failed urethroplasties for traumatic urethral injuries can be salvaged with a second reconstruction surgery. The procedure of choice for this salvage is anastomotic urethroplasty with techniques for tension-free anastomosis.

Surgical Outcome of Excision and End-to-End Anastomosis for Bulbar Urethral Stricture

Purpose

Although direct-vision internal urethrotomy can be performed for the management of short, bulbar urethral strictures, excision and end-to-end anastomosis remains the best procedure to guarantee a high success rate. We performed a retrospective evaluation of patients who underwent bulbar end-to-end anastomosis to assess the factors affecting surgical outcome.

Materials and Methods

We reviewed 33 patients with an average age of 55 years who underwent bulbar end-to-end anastomosis. Stricture etiology was blunt perineal trauma (54.6%), iatrogenic (24.2%), idiopathic (12.1%), and infection (9.1%). A total of 21 patients (63.6%) underwent urethrotomy, dilation, or multiple treatments before referral to our center. Clinical outcome was considered a treatment failure when any postoperative instrumentation was needed.

Results

Mean operation time was 151 minutes (range, 100 to 215 minutes) and mean excised stricture length was 1.5 cm (range, 0.8 to 2.3 cm). At a mean follow-up of 42.6 months (range, 8 to 96 months), 29 patients (87.9%) were symptom-free and required no further procedure. Strictures recurred in 4 patients (12.1%) within 5 months after surgery. Of four recurrences, one patient was managed successfully by urethrotomy, whereas the remaining three did not respond to urethrotomy or dilation and required additional urethroplasty. The recurrence rate was significantly higher in the patients with nontraumatic causes (iatrogenic in three, infection in one patient) than in the patients with traumatic etiology.

Conclusions

Excision and end-to-end anastomosis for short, bulbar urethral stricture has an acceptable success rate of 87.9%. However, careful consideration is needed to decide on the surgical procedure if the stricture etiology is nontraumatic.

Preliminary experimental study of urethral reconstruction with tissue engineering and RNA interference techniques

This study investigated the feasibility of replacing urinary epithelial cells with oral keratinocytes and transforming growth factor-β1 (TGF-β1) small interfering RNA (siRNA)-transfected fibroblasts seeded on bladder acellular matrix graft (BAMG) in order to reconstruct tissue-engineered urethra. Constructed siRNAs, which expressed plasmids targeting TGF-β1, were transfected into rabbit fibroblasts. The effective siRNA was screened out by RT-PCR and was transfected into rabbit fibroblasts again. Synthesis of type I collagen in culture medium was measured by enzyme-linked immuno sorbent assay (ELISA). Autologous oral keratinocytes and TGF-β1 siRNA-transfected fibroblasts were seeded onto BAMGs to obtain a tissue-engineered mucosa. The tissue-engineered mucosa was assessed morphologically and with the help of scanning electron microscopy. The TGF-β1 siRNA decreased the expression of fibroblasts synthesis type I collagen. Oral keratinocytes and TGF-β1 siRNA-transfected fibroblasts were seeded onto sterilized BAMG to obtain a tissue-engineered mucosa for urethral reconstruction. The compound graft was assessed using scanning electron microscope. Oral keratinocytes and TGF-β1 siRNA-transfected fibroblasts had a good compatibility with BAMG. The downregulation of fibroblasts synthesis type I collagen expression by constructed siRNA interfering TGF-β1 provided a potential basis for genetic therapy of urethral scar. Oral keratinocytes and TGF-β1 siRNA-transfected fibroblasts had good compatibility with BAMG and the compound graft could be a new choice for urethral reconstruction.

Evaluation of stretched electrospun silk fibroin matrices seeded with urothelial cells for urethra reconstruction

BACKGROUND

We investigated the feasibility of urethral reconstruction using stretched electrospun silk fibroin matrices.

MATERIALS AND METHODS

A novel electrospun silk fibroin matrix was prepared. The structure of the material was assessed by scanning electron microscopy and a porosity test. Canine urothelial cells were isolated, expanded, and seeded onto the material for 1 wk to obtain a tissue-engineered graft. The tissue-engineered graft was assessed using hematoxylin and eosin staining and scanning electron microscopy. A dorsal urethral mucosal defect was created in nine female beagle dogs. In the experimental group, tissue-engineered mucosa was used to repair urethra mucosa defects in six dogs. No substitute was used in the three dogs of the control group. Retrograde urethrography was performed at 1, 2, and 6 mo after grafting. The urethral grafts were analyzed grossly and histologically.

RESULTS

Scanning electron microscope and a porosity test revealed that the material had a three-dimensional porous structure. Urothelial cells grew on the material and showed good biocompatibility with the stretched silk fibroin matrices. Canines implanted with tissue-engineered mucosa voided without difficulty. Retrograde urethrography revealed no signs of stricture. Histologic staining showed gradual epithelial cell development and stratified epithelial layers at 1, 2, and 6 mo. The canines in the control group showed difficulty in voiding. Retrograde urethrography showed urethra stricture. Histologic staining showed that no or only one layer of epithelial cells developed. A severe inflammatory reaction was also observed in the control group.

CONCLUSIONS

Stretched electrospun silk fibroin matrices have good biocompatibility with urothelial cells, which could prove to be a potential material for use in urethra reconstruction.

Patient-reported outcomes combined with objective data to evaluate outcomes after urethral reconstruction

OBJECTIVE

To report patients' perceptions of urethral reconstruction outcomes by comparing the results from preoperative and postoperative symptom questionnaires and to propose a standardized method of follow-up that includes patient satisfaction questionnaires and objective cystoscopic evaluation to facilitate comparison of different urethral reconstructive techniques and outcomes among surgeons and institutions.

MATERIALS AND METHODS

Data were prospectively collected for 110 consecutive patients undergoing urethral reconstruction. Patient demographics, American Urological Association Symptom Score, quality of life score, International Index of Erectile Function score, flow rate, and postvoid residual urine volume were collected pre- and postoperatively. The patients were evaluated at 3 and 6 months postoperatively and then yearly. Flexible cystoscopy (17F) was performed at 6 months postoperatively. The Wilcoxon signed rank test and Mann-Whitney U test were used to compare the pre- and post-test distributions. One-way analysis of variance was used to compare the mean values among groups.

RESULTS

The mean patient age was 47 years, and the mean stricture length was 4.9 cm. Of the 110 patients, 32 received anastomotic (29%), 60 onlay (55%), 7 staged (6%), and 11 fasciocutaneous flap (10%) urethroplasty. The median individual change comparing the pre- and postoperative data was an improvement of 11 for the American Urological Association Symptom Score (P <.0001), 4 for the quality of life score (P <.0001), and 0 for International Index of Erectile Function (P = .05). No unifying individual follow-up questionnaire or flow rate correlated with recurrence.

CONCLUSION

Patients undergoing urethral reconstruction reported significant improvement in urinary bother and quality of life scores while maintaining or improving their erectile function. Cystoscopic evaluation can be a valuable component of the postoperative follow-up algorithm, providing a consistent data point for comparison and confirming the patency of repair. Standardization of the measured outcomes is critical to validate the reported urethral reconstructive outcomes.

[Preliminary resultson the use of autologous cell culture grafts of buccal mucosa in urethral repairs]

OBJECTIVE

We present our preliminary experience with the use of autologous cell cultures of buccal mucosa (BM) in urethral repair.

PATIENTS AND METHODS

Five patients with urethral stenosis underwent staged urethral reconstruction with MB autologous cell culture grafts. MB biopsies were obtained from each patient. Keratinocytes and fibroblasts were isolated. This cellular suspension was seeded into Petri dishes. The cultures were kept in chemically specific ground for keratinocyte cultures. Once they reached the proper confluence and extension for urethral reconstruction, the cultures were transplanted in the patients. During the first stage of surgery, after the removal of healing tissues, the MB culture grafts were transplanted in order to recreate a neo-urethral plate. Six months later, the neo-urethral plate was re-tubularized.

RESULTS

Average follow-up was 24 mo. We reported successful staged reconstruction in 2 cases (40%). Three cases (60%) were unsuccessful. One patient developed a scar retraction of the grafts after the first stage of surgery, which prevented broad urethral reconstruction. Two patients who had completed the staged reconstructive process,developed a re-stenosis. There were no reported graft site infections and none of the grafts was rejected.

CONCLUSIONS

We report the procedure in order to obtain and use an MB homologous cell culture. Using autologous material reduced the surgical time and wiped out the risk of rejection; on the other hand, the tissue was so thin and with no adequate scaffold that the healing retraction of the graft was increased, thus compromising the urethral reconstruction. Preliminary results confirm that bio- engineering applied to urethral surgery is far from obtaining adequate tissue with reference to extension, thickness and biological features.