The multistage use of buccal mucosa grafts for complex hypospadias: histological changes

Robot-Assisted Ureteroplasty with Labial Mucosal Onlay Grafting for Long Left-Sided Proximal Ureteral Stenosis in Children and Adolescents: Technical Tips and Functional Outcomes

Purpose: To evaluate functional outcomes of robot-assisted ureteroplasty with labial mucosa grafting for long proximal ureteral stenosis (LPUS) in children and adolescents. Methods: Included in this study were 15 patients who underwent robot-assisted ureteroplasty with labial mucosal grafting in our center between July 2017 and September 2021. The left affected stenotic ureter was repaired using labial mucosal grafting. If the ureter was simply strictured but not obliterated, the ureter was spatulated longitudinally along the ventral side and the labial mucosa graft was interposed and anastomosed in a continuous manner. Faced with the obliterated segment, it was excised and the spatulated portion re-anastomosed with a pelvic flap as the dorsal wall. The labial mucosa graft was placed as the ventral wall. The preoperative clinical data and follow-up outcomes were collected and evaluated. Results: Labial mucosa graft onlay ureteroplasty was well performed in all the 15 patients with no occurrence of intraoperative complications or surgical conversion. Five patients underwent an onlay ureteroplasty, and 10 patients underwent a dorsally augmented pelvic flap anastomotic ureteroplasty. The mean (range) stricture length was 7.1 (3-10) cm. The mean operative time was 371.2 (216-480) minutes, and the median blood loss was 40 mL. At the median follow-up of 35 months (range 12-58 months), the overall success rate was 93.3%. Conclusions: Labial mucosa grafting appears to be safe and feasible for repairing long ureteral strictures in pediatric and adolescent patients. Our experience may provide beneficial references and conveniences to solve complex problems in LPUS. This study was approved by the institutional review board, and written informed consent was obtained from each participant (ethics number: 2017-30).

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

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

Buccal Mucosa Tube Graft for Failed Hypospadias Repair: Worth it or Not?

OBJECTIVE

To report the outcome of buccal mucosa tube graft (BMTG) over time in correcting failed hypospadias.

METHODS

We conducted a retrospective analysis, reviewing charts of all 69 patients who underwent BMTG to repair hypospadias between January 2005 and October 2016. Twenty-one patients were excluded, leaving 48 eligible study subjects. In patients with penile curvatures, corrective procedures (including urethral division, corporoplasty, and local skin flap) took place prior to grafting.

RESULTS

Mean age at surgery was 8.96 years, and mean duration of follow-up was 73.10 ± 30.31 months. A mean of 1.88 previous surgeries was recorded. During follow-up, only 7 patients (14.5%) were complication free. The other 41 patients required at least 1 additional procedure. Stricture-free rates were 50%, 35.4%, and 27% at 1, 3, and 12 months after BMTG, respectively. Among 37 patients with postoperative stricture, 25 were treated only by endoscopic procedures. Single operation prior to BMTG (P= .004) and usage of larger catheter size (>8Fr) (P = .029) were confirmed significant factors associated with better stricture-free survival after BMTG by log-rank test. After several additional procedures, 46 patients (95.8%) reported normal urination with mean maximal urinary flow of 9.55 mL/s and post-void residual of 16.08 mL for at least 12 months on last visit.

CONCLUSION

BMTG after failed hypospadias repair seems prone to complications, primarily urethral stricture. However, a large number of patients with postoperative stricture could be treated simply by endoscopic procedures. Given the better results of staged approach, BMTG should be only applied to highly selected patients with failed hypospadias.

Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias

INTRODUCTION

To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair.

MATERIAL AND METHODS

Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated.

RESULTS

Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream.

CONCLUSIONS

Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.

MMP-2 and TIMP-2 expression, quantitative analysis and biomechanical changes in scar hypertrophy after autologous free transplantation of rabbit oral mucosa and scrotal skin

This study aimed to investigate the long-term scar hypertrophy in the rabbit transplanted oral mucosa and scrotal skin with changed matrix environment, as well as the scar location expression, quantitative analysis of matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of metalloproteinase-2 (TIMP-2) and biomechanical changes in the transplanted tissues. The split-thickness skin grafts were collected from the oral mucosas and scrotal skins of 30 male rabbits, and prepared into reelpipes for autologous transplantation into the rabbit back muscular tissues. Samples were collected to carry out elastic tensile mechanical detection and histological observation. The maximum longitudinal tensile displacement of scrotal skin before 8 weeks of transplantation was greater than that after 8 weeks of transplantation (P < 0.05). The expression intensities of MMP-2 and TIMP-2 in the oral mucosa and in scrotal skin at 2 W time point were higher than those at T _o time point (P < 0.05). The expression quantities of TIMP-2 in oral mucosa and scrotal skin during 8-24 W were higher than those of MMP-2 (P < 0.05). At 8 W time point, the TIMP-2/MMP-2 ratio in scrotal skin was higher than that in oral mucosa (P < 0.05). MMP-2 and TIMP-2 expression in normal oral mucosa and scrotal skin is weak, but their expression is remarkably up-regulated after 2 weeks of transplantation, revealing that scar formation was related to the high expression of MMP-2 and TIMP-2. At the 8th-24th weeks, the AOD values of TIMP-2 in oral mucosa and scrotal skin are apparently higher than those of MMP-2; moreover, the TIMP-2/MMP-2 ratio in scrotal skin at the 8th week was higher than that in oral mucosa, which can well explain the earlier scar formation in scrotal skin than in oral mucosa, and it also suggests that the different expression levels between TIMP-2 and MMP-2 may account for the important cause of scar formation.

Staged repair of redo and crippled hypospadias: analysis of outcomes and complications

INTRODUCTION

Residual curvature, scarred or absent urethral plate, shortage of skin, and paucity of vascularized tissues and flaps are all obstacles to overcome during repair of redo and cripple hypospadias after failed reconstruction. Limited articles address the outcome of repair of these cases using different grafts.

OBJECTIVE

An analysis of outcomes and complications after the repair of redo and cripple hypospadias in a cohort of children operated by a single surgeon is presented, and data are retrieved from a prospectively designed database.

STUDY DESIGN

Thirty-one children with a median age of 96 months (18-216, interquartile range [IQR]: 78), who underwent previous surgeries three to five times, were operated in the period from late 2011 to August 2017 in a single center by a single surgeon (first author); the first-stage repair was performed by using an inner prepuce graft in three children and oral grafts in 28 children. Penile straightening by degloving and removal of ventral scarred tissues are followed by development of glanular wings and grafting of the ventral surface.

RESULTS

Eleven distal penile hypospadias and 20 posterior hypospadias were operated. First-stage repair was revised in three children; 25 children, eight distal and 17 posterior hypospadias, underwent second-stage repair with a median age of 84 months (18-216, IQR: 60). The success rate after the second-stage repair was 56% (14 children), and complications were encountered in 11 children in the form of penoscrotal fistulae in four, complete dehiscence in one, and glanular dehiscence in six children. After closure of fistulae, the overall success rate increased to 72%. Although complications were more common among children with posterior hypospadias (nine children) than children with distal hypospadias (two children), no statistical significance was reached (p = .234), with no effect of age on complications (p = .233), no effect of the position of the meatus on glanular dehiscence (p = .624), and no effect of age on glanular dehiscence (p = .114).

CONCLUSION

Repair of redo and crippled hypospadias using staged graft repair in children could be achieved with a satisfactory overall success rate of 72%. Glanular dehiscence is the main complication; however, it is not considered by parents of children in the series, necessitating intervention. The lowest complication rate is expected among those with a position of the meatus more distal, however, not proven statistically in the series.

Two-stage graft urethroplasty for proximal and complicated hypospadias in children: A retrospective study

INTRODUCTION

Although two-stage graft urethroplasty is widely used, the literature regarding the complication rates and functional characteristics of reconstructed neourethra is relatively modest.

OBJECTIVES

The aim was to analyze the complication rates and uroflow data of boys who have previously undergone a two-stage graft urethroplasty procedure for proximal and complicated hypospadias.

PATIENTS AND METHODS

We retrospectively reviewed the clinical outcomes of 52 boys with proximal (n = 44) and complicated (n = 8) hypospadias who underwent two-stage graft urethroplasty repair (median age of 15 months and 3 years respectively) between 2004 and 2015. Fifteen toilet-trained boys without fistulas underwent uroflowmetry. The uroflow data were plotted on age-volume-dependent normograms with normal controls. The median follow-up was 34 months (8 months-8 years).

RESULTS AND COMPLICATIONS

Complications were identified in three patients (6%) after the first stage (i.e. contracture of the graft) and in 20 patients (38.4%) after the second stage, including meatal stenosis (n = 8, 15.3%), urethral stricture (n = 4, 7.6%), urethrocutaneous fistula (n = 8, 15.3%), glandular dehiscence (n = 1, 1.9%), and diverticulum (n = 1, 1.9%). The patients with failed hypospadias experienced fewer complications than those who underwent the two-stage procedure for primary repair (25% and 45%, respectively). The reoperation rate was 36.8%. Eleven of the 15 toilet-trained boys were asymptomatic but exhibited flow rates below the normal range (median Q_max = 7 mL/s, range 3.5-16.7). Only one of the boys with a low flow rate was confirmed to have urethral stenosis under general anesthesia.

DISCUSSION

In our study, primary hypospadias repair requiring urethral plate transection elicited worse outcomes than those observed in the prior failed hypospadias cases. However, because of our study's retrospective design, we were unable to accurately assess the initial position of the meatus in the redo hypospadias cases. Our data also demonstrated that the majority of cases without any voiding symptoms exhibited flow rates that were below the normal range despite no urethral stricture under general anesthesia. These findings indicate that urethras reconstructed via two-stage graft urethroplasty repair are not functionally equivalent to normal urethras, at least prior to puberty.

CONCLUSION

Two-stage graft urethroplasty repair was successful in 62% of cases after the second-stage procedure, but one-third of the boys required a reoperation after the two-stage planned repair. We demonstrated that although we used a urethral tissue substitute, the urine flow patterns of the patients without strictures were abnormal.

The Bracka two-stage repair for severe proximal hypospadias: A single center experience

Background:

Surgical correction of severe proximal hypospadias represents a significant surgical challenge and single-stage corrections are often associated with complications and reoperations. Bracka two-stage repair is an attractive alternative surgical procedure with superior, reliable, and reproducible results.

Purpose:

To study the feasibility and applicability of Bracka two-stage repair for the severe proximal hypospadias and to analyze the outcomes and complications of this surgical technique.

Materials and Methods:

This prospective study was conducted from January 2011 to December 2013. Bracka two-stage repair was performed using inner preputial skin as a free graft in subjects with proximal hypospadias in whom severe degree of chordee and/or poor urethral plate was present. Only primary cases were included in this study. All subjects received three doses of intra-muscular testosterone 3 weeks apart before first stage. Second stage was performed 6 months after the first stage. Follow-up ranged from 6 months to 24 months.

Results:

A total of 43 patients operated for Bracka repair, out of which 30 patients completed two-stage repair. Mean age of the patients was 4 years and 8 months. We achieved 100% graft uptake and no revision was required. Three patients developed fistula, while two had metal stenosis. Glans dehiscence, urethral stricture and the residual chordee were not found during follow-up and satisfactory cosmetic results with good urinary stream were achieved in all cases.

Conclusion:

The Bracka two-stage repair is a safe and reliable approach in select patients in whom it is impractical to maintain the axial integrity of the urethral plate, and, therefore, a full circumference urethral reconstruction become necessary. This gives good results both in terms of restoration of normal function with minimal complication.

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%.

Use of buccal mucosa grafts for urethral reconstruction in children: a retrospective cohort study

BACKGROUND

The use of buccal mucosa grafts (BMG) for urethral reconstruction has increased in popularity over the last several decades. Our aim was to describe our institutional experience with and outcomes after BMG urethroplasty.

METHODS

We conducted a retrospective cohort study of boys undergoing BMG urethral reconstruction. Preoperative and perioperative characteristics and postoperative outcomes were evaluated.

RESULTS

Twenty-nine patients (median age 8.2 years) underwent BMG urethroplasty from 1995-2012. Of the 10 patients undergoing 1-stage repairs, 6 had tubularized grafts, the last of which was performed in 2000 due to an unacceptably high revision rate (100%). A 2-stage approach was elected for 19 patients (median follow-up 21.3 months). Complications including stricture, fistula, or chordee were seen in 60% of patients completing both stages and 32% required ≥1 revision. However, 71% of 2-stage patients were free of significant problems at last follow-up.

CONCLUSIONS

We found BMG to be a reasonable option for use in complex pediatric urethral reconstruction. Tubularized grafts had poor results, and we no longer use them. We favor a 2-stage approach for all patients except those with "simple" non-hypospadiac strictures. Although revision procedures were not uncommon, the majority of patients were ultimately free of long-term problems.

Use of buccal mucosa in hypospadias repair

Hypospadias is an embryological disorder that results in an abnormal ventral positioning of the urethral meatus. Among multiple surgical techniques described to correct this anomaly, the use of buccal mucosa grafts has gained popularity among pediatric urologists, pediatric surgeons and plastic surgeons. Buccal mucosa grafts have shown favorable histological changes that result in an excellent scaffold for urethral reconstructive surgery. This review describes the evolution of the use of buccal mucosa grafts in hypospadias repair.

Histological and immunohistochemical changes in the rat oral mucosa used as an autologous urethral graft

PURPOSE

The purpose of this study was to determine the histological and functional (immunohistochemical) changes that take place in oral mucosa grafts implanted in the rat urethra.

METHODS

Urethroplasty was performed in 26 male Wistar rats weighing 250 g. All animals received autologous oral mucosa urethra grafting under general anesthesia. Samples were analyzed 10, 20, 30, 40, 50, 60, 90, and 120 days after surgery using light and scanning electron microscopy and immunofluorescence for the determination of the expression of epithelial markers (pancytokeratin, cytokeratin 1, 4, 13, and filaggrin).

RESULTS

Grafted oral mucosa tissues were subjected to significant histological changes from the beginning with the formation of a well-developed epithelium whose structure was comparable to the native urethra from day 60 of the surgical implant. The immunofluorescence analysis demonstrated that the cytokeratin expression profile tended to mimic the pattern of the native urethra. These data suggest that the oral mucosa is able to efficiently transdifferentiate to the urethral environment.

CONCLUSIONS

The efficient transdifferentiation process of the grafted oral mucosa at both the histological and immunofluorescence levels, and the absence of local complications confirm the clinical usefulness of this type of tissues for the repair of the urethra.

The role of two-stage repair in modern hypospadiology

Hypospadias surgery continues to evolve. The enthusiasm for flap-based urethroplasty is waning and instead there is an increasing preference for urethroplasty that uses either the urethral plate alone or in combination with grafts. From the vast armamentarium of hypospadias repairs that are still in use, the author suggests a simple protocol of just three closely related procedures with which we can now repair almost all hypospadias. The tubularised incised plate (TIP) repair and the ‘Snodgraft’ modification of the TIP principle are simple and effective one-stage solutions when partial circumference urethroplasty is required. Conversely, the Bracka two-stage graft repair remains an ideal and versatile solution when a full circumference urethroplasty is required. It is particularly appropriate for severe primary hypospadias associated with a poor plate and marked chordee and also to replace a scarred, hairy or balanitis xerotica obliterans diseased urethra in re-operative salvage hypospadias.

Two-stage repair in hypospadias

We provide the reader with a nonsystematic review concerning the use of the two-stage approach in hypospadias repairs. A one-stage approach using the tubularized incised plate urethroplasty is a well-standardized approach for the most cases of hypospadias. Nevertheless, in some primary severe cases, in most hypospadias failures and in selected patients with balanitis xerotica obliterans a two-stage approach is preferable. During the first stage the penis is straightened, if necessary and the urethral plate is substituted with a graft of either genital (prepuce) or extragenital origin (oral mucosa or postauricular skin). During the second stage, performed around 6 months later, urethroplasty is accomplished by graft tubulization. Graft take is generally excellent, with only few cases requiring an additional inlay patch at second stage due to graft contracture. A staged approach allows for both excellent cosmetic results and a low morbidity including an overall 6% fistula rate and 2% stricture rate. Complications usually occur in the first year after the second stage and are higher in secondary repairs. Complications tend to decrease as experience increases and use of additional waterproofing layers contributes to reduce the fistula rate significantly. Long-term cosmetic results are excellent, but voiding and ejaculatory problems may occur in as much as 40% of cases if a long urethral tube is constructed. The procedure has a step learning curve but because of its technical simplicity does not require to be confined only to highly specialized centers.

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.

Critical outcome analysis of staged buccal mucosa graft urethroplasty for prior failed hypospadias repair in children

PURPOSE

Although staged buccal mucosa graft urethroplasty is a well accepted technique for salvage urethroplasty, there are few reports on this procedure for redo hypospadias repair in children.

MATERIALS AND METHODS

We reviewed patients who underwent staged buccal mucosa graft urethroplasty for redo hypospadias repair. Age, quality of graft before tubularization, meatal position, presence of balanitis xerotica obliterans and complications were recorded.

RESULTS

A total of 30 patients underwent 32 repairs during a 5-year period. Mean age at first stage was 7 years (range 1 to 17) and mean interval between stages was 9.3 months (5 to 13). Mean followup after second stage was 25 months (range 10 to 46). Meatal position before first stage was proximal in 44% of patients, mid shaft in 39% and distal in 16%. Nine patients had biopsy proved balanitis xerotica obliterans. There were no donor site complications. Four patients underwent a redo grafting procedure. Complications after second stage occurred in 11 of 32 repairs (34%), consisting of urethral stenosis in 5, glanular dehiscence in 3 and urethrocutaneous fistula in 3. A third of the patients had some degree of graft fibrosis/induration after the first stage. These patients were prone to more complications at second stage (9 of 11, 82%), compared to patients without these unfavorable findings (4 of 21, 19%; p<0.001). Presence of balanitis xerotica obliterans and meatal position were not significant factors associated with adverse outcomes.

CONCLUSIONS

Staged buccal mucosa graft urethroplasty is a suitable technique for salvage urethroplasty. Complications after second stage were seen in approximately a third of patients, mainly those with fibrotic/indurated grafts.

Donor site morbidity in oral mucosa graft urethroplasty: implications of tobacco consumption

Background

The purpose of this prospective study was to evaluate the donor site morbidity in patients who have undergone oral mucosa graft urethroplasty for stricture of the urethra. The impact of smoking and oral consumption of tobacco and/or paan masala on the donor site was also assessed. This study is probably the first of its kind where the affect of smoking, paan masala and tobacco chewing on the donor site morbidity has been documented.

Methods

Forty-eight patients suffering from stricture of the urethra underwent oral mucosa graft urethroplasty between July 2005 and December 2007. The patients were divided into two groups (users or non-users) based on tobacco consumption and oral hygiene. The donor site was evaluated at frequent intervals for pain, swelling, numbness, bleeding, salivation and tightness of mouth.

Results

Donor site morbidity was more in users with poor oral hygiene. Pain scores were higher amongst the users and the morbidity persisted longer in the users compared to non-users with good oral hygiene.

Conclusion

Patients who consume tobacco and have poor oral hygiene should be warned regarding poorer outcomes after oral mucosa graft urethroplasty.

Histological evaluation of an alternative method of neophalloplasty based on two lower abdominal skin flaps and simultaneous buccal mucosa graft in the ventral surface of the neophallus (two-stage urethroplasty): experimental study in rabbits

OBJECTIVE

To evaluate, in an experimental study in rabbits, a new model of neophalloplasty based on two lower abdominal skin flaps and ventral buccal mucosa graft for planned two-stage urethroplasty procedure.

MATERIAL AND METHODS

Sixteen rabbits were operated and divided into four equal groups which were sacrificed at 2, 4, 8 and 12 weeks. The inflammatory pattern, presence of sub-epithelial fibrosis and epithelial changes in the grafted area were evaluated histologically.

RESULTS

There were no deaths and no dehiscence of the wound was seen. One animal in the 2-week group developed an ulcer in the grafted area. We found minimal contracture of the neophallus, but this was not statistically significant between groups. Buccal mucosa graft showed good uptake in all groups, with vascular support from subcutaneous tissue of the flaps. The grafted area developed epithelial metaplasia, showing a decrease in cell layers with time, with disappearance of the sub-epithelial papillae and appearance of stratum granulosum and keratinization of the epithelial graft surface. A decrease in sub-epithelial fibrosis with replacement of immature by mature (eosinophilic) collagen was found. In the later groups was also observed an important decrease in inflammatory response, and the chorion of the grafted area presented a dilated capillary network, indicating that the process of neoangiogenesis was effective.

CONCLUSION

Buccal mucosa displayed histological integration in the abdominal flaps with epithelial metaplasia in all groups. The surgical aspect of the neophallus was cosmetically acceptable, with minimal contracture.

Staged reconstruction of long segment urethral strictures in men with previous pediatric hypospadias repair

PURPOSE

Reconstruction of long segment urethral stricture disease in adults with a history of pediatric hypospadias repair remains complex secondary to poor urethral blood supply, extensive penile scarring and the need for significant amounts of graft or flap tissue. We describe our experience with staged urethroplasty in this cohort of men.

MATERIALS AND METHODS

A total of 15 males underwent staged urethroplasty for urethral stricture disease following previous hypospadias repair in childhood. All men underwent 2-stage repair with a minimum of 6 months separating each operation. Bulbar urethral stricture disease due to previous dilation was seen in 2 of the 15 men (14%). Graft sources included buccal mucosa in 12 cases, full-thickness hairless abdominal wall skin in 2, penile skin in 1 and posterior auricular tissue in 1.

RESULTS

Median patient followup was 22 months (range 5 to 62) after stage 2 closure. Median patient age at presentation was 31 years (range 19 to 57). Mean stricture length was 8 cm (range 5 to 14) and mean graft area was 22 cm(2) (range 10 to 38). There was no clinical evidence of stricture recurrence, fistula or wound dehiscence at last followup in 13 of the 15 men (86%). Two men with a congenital hypoplastic glans were left with distal hypospadias. Minor voiding symptoms were described in 3 of the 15 men (21%) with resolution in all by 6 months postoperatively.

CONCLUSIONS

We describe outcomes after staged reconstruction for extensive urethral stricture disease in men after previous pediatric hypospadias repair in childhood. At intermediate followup staged urethroplasty provided acceptable outcomes.

Donor site outcome after oral mucosa harvest for urethroplasty in children and adults

PURPOSE

We report short and long-term donor site outcomes after oral mucosa graft harvesting for urological reconstruction in a large series of patients including children, and identify possible risk factors for an untoward long-term outcome.

MATERIALS AND METHODS

A total of 78 patients were evaluated. Short-term outcomes included time to restore normal oral diet, perioral sensory defect/discomfort and jaw opening impairment occurring within 4 weeks of surgery. Long-term outcomes included donor site scarring, perioral sensory defect and jaw opening impairment occurring more than 1 year postoperatively. Long-term outcomes were assessed via a questionnaire administered to patients and on clinical examination by an oral surgeon. Outcomes were compared in children (younger than 12 years at surgery) and adults, and with regard to harvesting site, graft length, length of followup and other variables.

RESULTS

Two-thirds of the patients returned to a normal oral diet within 3 days postoperatively (range 1 to 8). All patients complained of perioral sensory defect/discomfort postoperatively, and 26% had jaw opening impairment. After a median followup of 7.6 years (range 1 to 13.2) perioral sensory defect was the most common complication observed (28%) in cases formally evaluated by an oral surgeon. The sensory defect was seldom perceived by the patients and never required treatment. It was statistically more common in patients undergoing surgery as adults, whereas none of the other variables proved significant.

CONCLUSIONS

Oral mucosa graft harvesting is safe irrespective of age. About a quarter of patients, more commonly adults, will have a long-term perioral sensory defect. However, the defect is never perceived as bothersome.

Hypospadias

Objective. The great possibility of variations in the clinical presentation of hypospadia, makes its therapy challenging. This has led to the development of a number of techniques for hypospadia repair. This article assesses past and present concepts and operative techniques with the aim of broadening our understanding of this malformation. Materials and Methods. The article not only reviews hypospadia in general with its development and clinical presentation as well as historical and current concepts in hypospadiologie on the basis of available literature, but it is also based on our own clinical experience in the repair of this malformation. Results and Conclusion. The fact that there are great variations in the presentation and extent of malformations existent makes every hypospadia individual and a proposal of a universal comprehensive algorithm for hypospadia repair difficult. The Snodgrass technique has found wide popularity for the repair of distal hypospadias. As far as proximal hypospadias are concerned, their repair is more challenging because it not only involves urethroplasty, but can also, in some cases, fulfil the dimensions of a complex genital reconstruction. Due to the development of modern operating materials and an improvement in current surgical techniques, there has been a significant decrease in the complication rates. Nonetheless, there still is room and, therefore, need for further improvement in this field.

Retalhos tubulares de pele de ratos com dois tipos de cateter de silicone

OBJETIVO: Avaliar o processo inflamatório e a fibrose em retalhos tubulares confeccionados na pele do dorso de ratos Wistar, moldados com cateteres de silicone com diferenças de resistência à compressão diametral. MÉTODO: Vinte ratos Wistar foram submetidos à confecção de três retalhos tubulizados de pele em região dorsal. Um retalho não foi moldado e os outros dois receberam, respectivamente, como molde interno, durante um período de sete dias, cateteres de silicone com diâmetros iguais e diferentes resistências à compressão diametral. Os animais foram divididos em dois grupos e sacrificados, respectivamente, no sétimo e vigésimo primeiro dia após a cirurgia. Realizou-se estudo histopatológico para a avaliação da fibrose e do processo inflamatório. RESULTADOS: Não foram encontradas diferenças significativas quanto à presença de fibrose ou processo inflamatório entre os três grupos estudados. CONCLUSÃO: A presença do cateter de silicone, independente de sua resistência à compressão diametral, não aumentou a intensidade da reação inflamatória e da fibrose nas margens suturadas de retalhos tubulares da pele de ratos Wistar.