Does Closure of the Buccal Mucosal Graft Bed Matter? Results From a Randomized Controlled Trial

Comparison of closure versus non-closure of the intraoral buccal mucosa graft site in urethroplasties. A systematic review and meta-analysis

Aim

To assess postoperative oral morbidity through meta-analysis of comparative studies for closure or non-closure of the buccal mucosa graft harvest area in patients undergoing urethroplasty.

Methods

A systematic literature review was conducted in January 2022. Randomized controlled studies were assessed according to the Cochrane collaboration guidelines. Postoperative pain, difficult mouth opening, alteration of oral salivation, perioral numbness, and tolerance of solid and liquid intake results were assessed. Standard mean differences and risk ratios with 95% confidence intervals were estimated for relative risk. Assessment was performed with subgroup analyses according to time points.

Results

This meta-analysis included 373 patients in 7 randomized studies. The oral pain overall pooled effect estimates were investigated for the time points of day 0-1, day 3-7 and months 1-6. According to corrected effect estimates after sensitivity analysis, at the day 0-1 time point, the non-closure group was significantly superior compared to the closure group. But there was no difference at the other time points and in total. The overall pooled effect estimates for difficult mouth opening were investigated at 4 time points (day 1, days 5-7, months 1-3 and months 6). After sensitivity analysis, the overall pooled effect estimates at 6 months were significantly superior for the non-closure group. There were no significant differences between the non-closed and closed groups based on the overall pooled-effect estimates for oral numbness, salivary secretion alteration, and tolerance of liquid and solid food variants.

Conclusion

The non-closure group was more advantageous in terms of oral pain in the early postoperative period. There were no differences between the groups in terms of alteration of salivation, oral numbness and toleration of liquid/solid food. Although the non-closed group seems more advantageous in terms of ease in mouth movements, more studies are needed to prove this.

Oral adverse outcomes associated with the buccal mucosa graft for urethroplasty

OBJECTIVE

The buccal mucosa graft (BMG) is the standard graft for reconstructive urology, but management of the donor site remains under debate. The authors compared postoperative oral adverse outcomes between management methods (closure, nonclosure, or xenograft-assisted closure).

STUDY DESIGN

A retrospective cohort study was conducted, enrolling patients treated at Harborview Medical Center, Seattle, Washington. The patients had a history of urethroplasty using a unilateral BMG, and the primary outcome variables were postoperative oral adverse outcomes, defined as subjective changes in mouth opening, smile, chewing, speech, intraoral bleeding, paresthesia, trismus, and infection. Multivariate and regression analyses were performed.

RESULTS

The sample was composed of 137 patients (95% male; mean age, 48 years). The mean surface areas of the BMG for closure, nonclosure, and xenograft were 1059, 1178, and 1228 mm², respectively. Thirty-four patients completed the survey (7 closure, 17 nonclosure, and 10 xenograft). Multiple linear regression showed a significant difference between the 3 groups with respect to patient-reported chewing ability and trismus favoring xenograft at larger graft sizes (P < .01).

CONCLUSIONS

Xenograft-assisted closure may reduce long-term oral adverse outcomes associated with trismus and subjective changes in chewing, mouth opening, speaking, and smiling with larger grafts. In addition, limited postoperative patient education for oral rehabilitation exercises was noted.

Determining Perioperative Practice Patterns in Urethroplasty: A Survey of Genitourinary Reconstructive Surgeons

OBJECTIVE

To better delineate perioperative urethroplasty practice patterns among reconstructive urologists given that management strategies in reconstructive urology have generally been poorly described.

METHODS

An online survey examining perioperative management of anterior urethroplasty patients was administered to Society of Genitourinary Reconstructive Surgeons (GURS) members between August-October 2019. Questions pertained to tissue transfer, pharmacologic prophylaxis, catheter use, follow-up, and post-operative care.

RESULTS

A total of 248 GURS members were invited to participate, with a response rate of 57.2% (n = 142). Most participants performed >20 urethroplasties per year (n = 108, 76.1%). Almost all respondents (97.9%, n = 139) used intraoperative intravenous antibiotics. A minority of surgeons used intraoperative pharmacologic thromboembolism prophylaxis (n = 57, 40.1%). Surgeons prefer buccal mucosa for grafting (n = 138, 97.2%) with many leaving the donor site open (n = 76, 53.5%). Only 21.8% (n = 31) of surgeons prescribe bedrest for patients and 25.4% (n = 36) routinely place drains. Postoperatively, oral antimicrobials are routinely administered (n=100, 70.4%), with most continuing until the urinary catheter is removed (70, 72.2%). Patients commonly had a urethral catheter for 2-3 (n = 72, 58.5%) or 3-4 weeks (n = 37, 30.1%). At catheter removal, surgeons routinely perform urethral imaging with contrast (n=96, 67.6%). Most surgeons prefer some form of objective investigation (n = 111, 78.2%) (uroflowmetry [n = 91, 82.0%], post-void residual [n = 88, 79.3%]). Cystoscopy is also commonly performed (n = 64, 57.7%). These investigations are routinely performed at 2-3 (n = 49, 44.2%) or 4-6 months (n = 38, 34.2%) postoperatively.

CONCLUSION

Despite general consensus on urethroplasty management options, heterogeneity remains in the areas of antibiotic use, VTE prophylaxis, donor site management, catheter management, and follow-up assessment.

Buccal Mucosa Graft Harvest in Children and Young Adults: Case Series and Harvest Technique

Buccal mucosa is a great choice for urethroplasty for urethral stricture repair because of ease of harvesting, pliability of the graft, and minimal donor site morbidity. These procedures are performed at our institution as a combined case with Pediatric Otolaryngology and Urology. Harvesting buccal mucosal grafts in younger patients is more technically challenging due to limited oral cavity access and smaller area available for tissue harvest, but is able to be performed safely and with limited morbidity with the addition of parotid duct cannulation and use of retraction sutures to the graft harvest technique. This retrospective case series reports harvest technique, outcomes, and complications of children and young adult males undergoing buccal or lower lip mucosal graft harvesting to repair congenital urethral strictures. Outcome measures were perioperative bleeding, trismus, pain, numbness, parotid duct injury and lip deformity. Six patients underwent nine harvest procedures. Technique modifications included application of anterior graft margin stay sutures to help stabilize the graft mucosa and cannulation of the parotid duct with lacrimal probes to avoid duct injury and to maximize graft size. Overall, buccal mucosal graft harvesting is a well-tolerated procedure with minimal complications using proper harvest technique.

A Systematic Review of Randomized Controlled Trials Comparing Buccal Mucosal Graft Harvest Site Non-Closure versus Closure in Patients Undergoing Urethral Reconstruction

Purpose

To assess the effects of buccal mucosal graft site non-closure versus closure on postoperative oral morbidity for male undergoing augmentation urethroplasty for urethral stricture.

Materials and Methods

We included randomized controlled trials. Inclusion criteria were male over the age of 18 with urethral stricture disease requiring reconstruction with buccal mucosal graft harvest. Primary outcomes of the review were postoperative oral pain, need for secondary oral procedures and cosmetic defects.

Results

We included 5 studies with 346 randomized patients with urethral strictures, of whom 260 completed the trials. In terms of primary outcomes, non-closure graft site may reduce oral pain on postoperative day #1 (standard mean difference [SMD] 0.24 lower; 95% confidence interval [CI] 0.61 lower to 0.12 higher; low certainty evidence [CoE]) but we are uncertain how this impacts pain on postoperative days 3 to 6 (SMD 0.35; 95% CI 0.12 to 0.81 higher; very low CoE). We are also very uncertain as to how it affects the need for secondary oral procedures (risk ratio [RR] 0.22; 95% CI 0.01 to 4.28; very low CoE). Non-closure may increase the risk of cosmetic defects (RR 2.40; 95% CI 0.93 to 6.22; low CoE).

Conclusions

This review describes the trade-off for buccal mucosal graft site non-closure versus closure for various patient-important outcomes; decision-making will likely hinge on the relative value individual patients and surgeons place on them. The supporting evidence was rated as low and very low, thereby signaling substantial underlying uncertainty and the need for better trials.

Outpatient buccal mucosal graft urethroplasty outcomes are comparable to inpatient procedures

Background

We sought to compare outcomes between inpatient and outpatient buccal mucosal graft (BMG) urethroplasty among a large tertiary referral center series.

Methods

A retrospective review of consecutive patients who underwent BMG urethroplasty between 2007 and 2018 was performed, including only first stage and one stage graft procedures. Patients were divided into inpatient and outpatient groups. Demographic and outcome data were collected and analyzed, with success defined as no need for further endoscopic or open reoperative management.

Results

Of 143 patients undergoing BMG urethroplasty during the study period, 87 cases (60.8%) were performed on an inpatient basis, and 56 (39.2%) on an outpatient basis. Patient characteristics such as age, BMI, prior endoscopic procedures and co-morbid factors were similar between inpatient and outpatient groups. Perioperative characteristics such as estimated blood loss were also similar between groups, but the inpatient cohort had a longer operative time (157.6 vs. 123.1 min, P<0.0001). Operative success was comparable in the two groups (74.7% inpatient vs. 76.8% outpatient, P=0.7) as were rates of complications (29.9% inpatient vs. 26.8% outpatient, P=0.07).

Conclusions

BMG urethroplasty can be safely performed in an ambulatory setting without increased complications or compromised outcomes.

Oral mucosa grafting in periorbital reconstruction

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

Fasciocutaneous flap reinforcement of ventral onlay buccal mucosa grafts enables neophallus revision urethroplasty

BACKGROUND

Urethral strictures or fistulas are common complications after phalloplasty. Neourethral defects pose a difficult reconstructive challenge using standard techniques as there is generally insufficient ventral tissue to support a graft urethroplasty. We report our experience with local fasciocutaneous flaps for support of ventrally-placed buccal mucosal grafts (BMGs) in phalloplasty.

METHODS

A retrospective review of patients who underwent phalloplasty and subsequently required revision urethroplasty using BMGs between 2011 and 2015 was completed. Techniques, complications, additional procedures, and outcomes were examined.

RESULTS

A total of three patients previously underwent phalloplasty with sensate radial forearm free flaps (RFFFs): two female-to-male (FTM) gender reassignment, and one oncologic penectomy. Mean age at revision urethroplasty was 41 years (range 31-47). Indications for surgery were: one meatal stenosis, four urethral strictures (mean length 3.6 ± 2.9 cm), and two urethrocutaneous fistulas. The urethral anastomosis at the base of the neophallus was the predominant location for complications: 3/4 strictures, and 2/2 fistulas. Medial thigh (2) or scrotal (1) fasciocutaneous flaps were used to support the BMG for urethroplasty. One stricture recurrence at 3 years required single-stage ventral BMG urethroplasty supported by a gracilis musculocutaneous flap. All patients were able to void from standing at mean follow up of 8.7 months (range 6-13). A total of two patients (66%) subsequently had successful placement of a penile prosthesis.

CONCLUSIONS

Our early results indicate that local or regional fasciocutaneous flaps enable ventral placement of BMGs for revision urethroplasty after phalloplasty.

Primary dorsal buccal mucosa graft urethroplasty for anterior urethral strictures in patients with lichen sclerosus

PURPOSE

To report our ongoing experience with dorsal buccal mucosa graft (BMG) urethroplasty for the primary repair of anterior urethral strictures in patients with lichen sclerosus (LS).

PATIENTS AND METHODS

A total of 32 men with LS underwent BMG urethroplasty from January 2010 to September 2012. In 27 patients, stricture was limited to the penile urethra, while in five patients, both bulbar and penile urethra were involved. In these five patients, the entire anterior urethra was replaced with BMG. In nine (28.1%) younger patients (mean age 38.2 years, range 33-45), with adverse local conditions and significant scarring, two-stage repair was done. The paired t test was performed on preoperative and postoperative Qmax as well as on preoperative and postoperative post-void residual urine volume, and the Fisher exact test was used to assess success between treatment groups. The chi-squared test was used to compare categorical data.

RESULTS

The overall success rate was 90.6%. Complications occurred in 9.4% of the patients (3 of 32) including hematoma in two patients and fistula in one patient. In this cohort of patients, mean preoperative Qmax was 6.2 ml per second (range 2.6-10.2) versus 18.2 (range 15.8-21.2) postoperatively (at 9 months), which was statistically significant (p < 0.002). Also, mean preoperative post-void residual urine volume was 110 ml (range 75-180) versus 19 ml (range 10-40) postoperatively at 9 months, which was statistically significant (p < 0.004).

CONCLUSION

Buccal mucosa is the most reliable graft for repairing anterior urethral strictures in patients with LS. Minimal complications are observed, even in cases of long stenosis completely afflicting anterior urethra.

Impact of Short-Stay Urethroplasty on Health-Related Quality of Life and Patient's Perception of Timing of Discharge

Objective. To evaluate health-related quality of life in patients after a short-stay or outpatient urethroplasty. Methods. Over a 2-year period a validated health-related quality-of-life questionnaire, EuroQol (EQ-5D), was administered to all patients after urethroplasty. Postoperatively patients were offered to be sent home immediately or to stay overnight. Within 24 hours after discharge they were assessed for mobility, self-care, usual activities, pain or discomfort, and anxiety and depression. An additional question assessing timing of discharge was added to the survey. Clinical and operative characteristics were examined. Results. Forty-eight patients after anterior urethroplasty completed the survey. Mean age and mean stricture length were 51.6 years (21–78) and 60 mm (5–200 mm), respectively. Most etiologies were idiopathic (50% n = 24), trauma (19%, n = 9), and iatrogenic (19%, n = 9). Forty-one patients (85%) stayed overnight, while 7 patients (15%) chose to be discharged the same day. Overall, ninety-six percent were discharged within 23 hours of surgery. In the short-stay and the outpatient cohorts, 90% and 86%, respectively, felt they were discharged on time. No patient reported a severe problem with postoperative pain or mobility. Conclusions. The majority of patients discharged soon after their procedure felt that discharge timing was appropriate and their health-related quality of life was only minimally affected.

Healing of Donor-site Buccal Mucosa Urethroplasty

Buccal mucosal graft represents the gold standard graft material for urethroplasty because of its thick epithelium and a thin lamina propria for maximal graft uptake. There is an ongoing debate whether to close the buccal graft donor site. We show a unique look at buccal donor site healing through serial pictures over a 100-day period. In this patient, the anterior half of the buccal donor site was closed at the time of harvest, allowing real-time observation of wound healing from both the closed and open aspects of the wound.