Long-term followup of buccal mucosa onlay graft for hypospadias repair: analysis of complications

Bilateral Buccal Mucosa Graft for Urethroplasty: A Versatile Graft

Male urethral stricture is scarring of the urethral tissue that narrows the urethral lumen causing reduced urinary flow. Urethral reconstruction or substitution urethroplasty using oral mucosa graft, especially from the buccal mucosa, is one of the most widely known techniques to manage urethral stricture. However, studies using bilateral buccal mucosa are still limited. Therefore, this study aims to report our experience and technique of bilateral buccal mucosa grafting for urethroplasty. The authors described a 66-year-old man with long-segment urethral stricture that was successfully treated with urethral reconstruction harvested from bilateral buccal mucosa.

A comparative study of two single-stage oral mucosal substitution urethroplasty (Kulkarni and Asopa) in the surgical treatments of lichen sclerosus urethral strictures

Long-segment lichen sclerosus (LS) urethral stricture is a challenge for urologists. Limited data are available for surgeons to make a surgical decision between Kulkarni and Asopa urethroplasty. In this retrospective study, we investigated the outcomes of these two procedures in patients with LS urethral stricture. Between January 2015 and December 2020, 77 patients with LS urethral stricture underwent Kulkarni and Asopa procedures for urethroplasty in the Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine (Shanghai, China). Of the 77 patients, 42 (54.5%) underwent the Asopa procedure and 35 (45.5%) underwent the Kulkarni procedure. The overall complication rate was 34.2% in the Kulkarni group and 19.0% in the Asopa group, and no difference was observed ( P = 0.105). Among the complications, no statistical difference was observed in the incidence of urethral stricture recurrence ( P = 0.724) or glans dehiscence ( P = 0.246) except for postoperative meatus stenosis ( P = 0.020). However, the recurrence-free survival rate between the two procedures was significantly different ( P = 0.016). Cox survival analysis showed that antiplatelet/anticoagulant therapy use ( P = 0.020), diabetes ( P = 0.003), current/former smoking ( P = 0.019), coronary heart disease ( P < 0.001), and stricture length ( P = 0.028) may lead to a higher hazard ratio of complications. Even so, these two techniques can still provide acceptable results with their own advantages in the surgical treatment of LS urethral strictures. The surgical alternative should be considered comprehensively according to the patient characteristics and surgeon preferences. Moreover, our results showed that antiplatelet/anticoagulant therapy use, diabetes, coronary heart disease, current/former smoking, and stricture length may be contributing factors of complications. Therefore, patients with LS are advised to undergo early interventions for better therapeutic effects.

Off-the-shelf acellular fetal skin scaffold as a novel alternative to buccal mucosa graft: the development and characterization of human tissue-engineered fetal matrix in rabbit model of hypospadiasis

AIM

In this study, we aimed to develop a novel alternative to buccal mucosal graft from the acellular human fetal skin to manage hypospadias in a rabbit model. We optimized the decellularization protocol to develop and characterize the human tissue-engineered fetal dermal matrix as an "off-the-shelf" natural biomaterial.

MATERIAL AND METHODS

Human fetal skin was obtained at 16-19 weeks gestational age with respect to a signed informed consent from parents under the university ethical committee approval. The dissected full-thickness fetal skin tissues were placed into SDS and Triton X-100 in different dosages to achieve the optimum decellularization protocol. Histopathology of the acellular fetal matrix was assessed by Hematoxylin & Eosin (H&E) and DAPI staining to confirm the removal of all cell materials, Masson's trichrome staining for collagen evaluation, DNA quantification for confirmation of DNA content, and scanning electron microscopy (SEM) for evaluation of scaffold microstructure. Immunohistochemistry (IHC) staining was used to detect specific dermal markers, namely vimentin, type I collagen, cytokeratin (CK)19. The prepared dermal scaffolds were then grafted on the 8 rabbit models of hypospadias. The rabbits underwent evaluations at 1, 2, 3, and 6 months postoperatively.

RESULTS

H&E, Masson's trichrome, DAPI staining, and SEM confirmed the significant removal of cells; meanwhile, the ECM was completely preserved. At the time of biopsy, after 2, 4, and 6 months, no evidence of inflammation, fibrosis, necrosis, or rejection was observed. The grafted dermal scaffolds appeared histologically and anatomically normal. It was observed that the scaffolds were recellularized by circulating CD 34 + bone marrow stem cells (BMSCs) inside the body, implicating the body as a natural bioreactor.

CONCLUSION

The application of acellular fetal skin (AFS) is a safe and feasible method that can decrease surgical time in a complex hypospadias reconstruction. Moreover, AFS demonstrated excellent angiogenesis characteristics and migration of the stem cells to the scaffold observed during the course of treatment. Novel natural AFS scaffold without cell seeding is an excellent alternative to buccal mucosal graft; hence, it can overcome the limitations concerning the graft size and prevent the creation of wounds in oral mucosal tissue.

Adults with previous hypospadias surgery during childhood: Beware of bulbar strictures

BACKGROUND

Urethral strictures represent the most frequent long-term complication in men after history of hypospadias surgery.

OBJECTIVES

To better define the spectrum of men previously treated for hypospadias during childhood, presenting at an adult urology clinic with persistent urethral complications.

STUDY DESIGN

Retrospective review of the records of 42 consecutive adult patients with a personal history of hypospadias repair during childhood referred at one adult tertiary urology center between 2004 and 2017. Those with persistent urethral strictures were included: 28 patients (median age 28yr [17-81]). Residual chordee, aesthetic concerns, isolated fistulas, and motives of consultation unrelated to hypospadias were excluded. Early initial success rate and location of urethral stricture were studied. Statistical Analysis was done by non-parametric tests.

RESULTS

On the 42 consecutive adults eligible, a total of 28 patients had a persistent urethral stricture. During childhood, 13/28 boys had required multiple surgical revision procedures, including six of them for postoperative urethral strictures. During adulthood, initial urethral assessment revealed 29 urethral strictures in 28 patients (penile urethra 23/29, bulbar urethra 8/29). The early initial success rate of stricture treatment was 50% (median follow-up: 4 years [1-7]). Additional surgical procedures were needed and performed in 11 patients. Eight patients were eventually diagnosed with a bulbar stricture, either isolated (n = 5) or combined with a distal stricture (n = 3), without significant relationship with initial position of meatus.

DISCUSSION

Predictive factors for bulbar strictures locations could not be identified. It was however observed that symptomatic bulbar strictures do exist in adults, in the long term after penile hypospadias repair during childhood, independently of the initial site of hypospadias, initial success of primary repair, and the type of surgical reconstructions performed during childhood.

CONCLUSION

Bulbar strictures represent more than 25% of the overall strictures diagnosed in adult patients treated for hypospadias during childhood, independently of the original site of urethral reconstruction.

Promising results for hypospadias repair using alloderm® (Regen): A randomized controlled trial

INTRODUCTION;: Hypospadias is a congenital disorder of urethra in which meatus is not at its correct place and occurs in 1 of 250 live male birth. Many techniques have been used for the repair of hypospadias and to decrease the incidence of fistula. Alloderm has been recently used for the repair of urologic congenital defects, and reconstructive surgeries, but not used in hypospadias in a randomized controlled trial. Therefore, the aim of this study was to assess the efficacy of Alloderm® (Regen) to reduce fistula rate in hypospadias repair.

METHODS & MATERIALS

This was a randomized controlled trial. Sixty patients were divided into two groups, 30 children underwent surgery using Alloderm® (Regen) as the Alloderm group and 30 without using it as controls. In the Alloderm group, 21 underwent primary surgery (12 mid-shaft hypospadias who underwent concurrent chordee correction and urethroplasty, and 9 penoscrotal who underwent 2 stage surgery, chordee was first corrected and then 6 months later TIP was performed), and 9 underwent fistula repair due to previous surgeries. In the control group, 24 patients underwent primary surgery (15 mid-shaft, and 9 penoscrotal) and 6 fistula repair the same as the Alloderm group but without using Alloderm.

RESULTS

There was no meaningful difference between the two groups regarding age (P = 0.634). There was no meaningful difference regarding the operation type between the two groups (P = 0.371). There was no meaningful difference regarding the meatal location between the two groups (P = 0.781). There were no significant post-operative complications in the both groups. No bleeding or diverticulum occurred. Recurrence of fistula occurred in one patient in the Alloderm group after fistula repair and in 2 in the control group. Overall, In the Alloderm group, 3 (2 after TIP and 1 after fistula repair) patients and in the control group 8 (6 after TIP, 2 after fistula repair) patients developed fistulas after surgery (10% vs 26.7%). There was a statistically meaningful difference regarding fistula formation between the two groups using Chi-square test (P = 0.014).

CONCLUSION

Alloderm® (Regen) can be used for hypospadias and fistula repair with very few complications and good results. Fistula was less probably occurred in the Alloderm group compared to the standard repair of hypospadias.

Effects of Anti-Inflammatory Nanofibers on Urethral Healing

Protracted postsurgical inflammation leading to postoperative complications remains a persistent problem in urethral reconstruction. Nanofibers in the form of peptide amphiphiles expressing anti-inflammatory peptides (AIF-PA) have positively modulated local inflammatory responses. Urethroplasty is performed to repair 5 mm ventral urethral defects with: uncoated small intestinal submucosa (SIS); SIS dip-coated with AIF-PA1 (anti-inflammatory treatment), or SIS dip-coated with AIF-PA6 (control) on 12-week-old male Sprague Dawley rats (n = 6/group/timepoint). Animals are euthanized at 14 and 28 d postsurgery. Hematoxylin-eosin, Masson's Trichrome, and immunohistochemistry with primary antibodies against myeloperoxidase (MPO; neutrophils), CD68, CD86, CD206 (macrophages), and proinflammatory cytokines TNFα and IL-1β are performed. Complete urethral healing occurs in 3/6 uncoated SIS (50%), 2/6 SIS+AIF-PA6 (33.3%), and 5/6 SIS+AIF-PA1 (83.3%) animals at 14 d and all at 28 d. Application of AIF-PA1 to SIS substitution urethroplasty decreases MPO⁺ neutrophils, CD86⁺ M1 proinflammatory macrophages, TNFα, and IL-1β levels while concurrently increasing levels of CD206⁺ M2 proregenerative/anti-inflammatory macrophages at the anastomoses and the regenerated tissue at the wound bed (REGEN). AIF-PA1 treatment enhances the healing process, contributing to earlier, complete urethral healing, and increased angiogenesis. Further studies are needed to elucidate the specific mechanism of inflammatory response modulation on angiogenesis and overall urethral healing.

Hyperbaric oxygen therapy for pediatric "hypospadias cripple"-evaluating the advantages regarding graft take

INTRODUCTION

Hypospadias cripple patients pose a major surgical challenge with high complication rates attributed mainly to graft contraction. Hyperbaric oxygen therapy (HBOT) is an established treatment for compromised grafts and used extensively as a salvage therapy for compromised grafts and ischemic non-healing wounds.

OBJECTIVE

We evaluated the graft-take rates in hypospadias cripple cases undergoing a staged tubularized autograft repair (STAG) and compared between patients treated with or without preemptive HBOT.

MATERIALS AND METHODS

All patients underwent a STAG. Patients receiving preemptive HBOT were compared with patients receiving the standard surgical procedure without HBOT. The HBOT protocol included a daily session, 5 days per week for four weeks before the surgery and 10 additional daily sessions immediately after first-stage surgery. Each HBOT session included 90 min exposure to 100% O₂ at 2 atmospheres absolute with 5 min air breaks every 20 min. The primary endpoint was graft take. Sequential tubularization without tension at second stage was defined as success.

RESULTS

Seven boys received HBOT and 14 boys comprised the control group. All patients in the HBOT group had good graft take with no graft contraction. In the control group, 57% had good graft take and could proceed to the second-stage surgery and 43% had graft contraction (Table). Except for one patient who had claustrophobia while entering the chamber, no significant side-effects developed during the HBOT.

DISCUSSION

The basic pathophysiology of compromised flaps includes both ischemia and reperfusion injury, which can be attenuated by HBOT. The beneficial effects of HBOT relates to several mechanisms, including hyperoxygenation, fibroblast proliferation, collagen deposition, angiogenesis, and vasculogenesis. Graft contraction is a well-known complication in hypospadias cripple population with reported failure rate of 39-63%. The HBOT procedure was found to be very effective and the entire HBOT group had a good graft take. Accordingly, all patients in the HBOT group proceeded to a successful second-stage tubularization. In addition, HBOT was found to be safe and generally well tolerated by this pediatric population. Study limitations were a relative small, non-homogenous sample size and lack of prospective randomization. Success was defined as sufficient graft elasticity sufficing for tubularization of the neourethra, and exact graft measurements are lacking in this study.

CONCLUSIONS

Preemptive HBOT can be used safely in the hypospadias cripple pediatric population and can potentially reduce the expected high surgical failure secondary to graft contraction.

Staged male genital reconstruction with a local flap and free oral graft: a case report and literature review

Background

Male genital skin loss is a common disease in urology. However, male genital skin loss accompanying a penile urethra defect is rarely reported. Herein, we describe a novel surgical technique using a composite local flap and oral mucosal graft to reconstruct the penis, which may provide a new solution for patients with similar conditions.

Case presentation

A 36-year-old male with a penile urethra defect and a large area of genital skin loss required urethral reconstruction. The meatus had descended to the penoscrotal junction. This procedure was divided into three stages. The first stage of the surgery involved burying the nude penile shaft beneath the skin of the left anteromedial thigh for coverage of the skin defect. The second stage consisted of releasing the penis and expanding the size of the urethral plate for further urethroplasty. The third stage consisted of reconstruction of the anterior urethra 6 months later. Postoperatively, the patient reported satisfactory voiding. The maximal flow rate (MFR) was 22.2 ml/s with no postvoiding residual urine at the 24-month follow-up visit. No edema, infection, hemorrhage, or cicatricial retraction were observed. The patient’s erectile function was satisfactory, and his international index of erectile function-5 score (IIEF-5 score) was 23 at the 24-month follow-up visit. Additionally, the presence of nocturnal penile tumescence demonstrated that he had normal erectile function.

Conclusions

This procedure is an effective surgical option for men with complete foreskin and penile urethra defects. It could also be extended as a treatment strategy when composite local or pedicle transposition flaps and free grafts are needed for specific patients.

Outcomes of staged lingual mucosal graft urethroplasty for redo hypospadias repair

BACKGROUND

The objective of this study was to present the outcomes for redo hypospadias repair using lingual mucosal graft (LMG).

PATIENTS AND METHODS

Between June 2012 and February 2017, 47 patients underwent staged LMG urethroplasty for redo hypospadias repair. The inclusion criteria were previous failed hypospadias repair with a paucity of local skin that interferes with correction using skin flaps and demands graft urethroplasty. During the first stage, a well-vascularized bed on the tunica albuginea was created. Then, the harvested LMG was secured to the prepared bed. The second-stage urethroplasty was carried out after six months. In this stage, tubularization of the previously implanted LMG was performed. In four cases, tubularization was difficult owing to graft contracture. This difficulty was managed by using the dorsally degloved penile skin as the onlay island flap in three cases and the buccal mucosa onlay graft in the fourth case. In all cases, a second protective layer from the dartos or tunica vaginalis was developed to cover the neourethra.

RESULTS

The median (interquartile range [IQR]) age of patients at the first stage was 5 (4-6) years, and the median (IQR) duration between both stages was 7 (6-8) months. The median (IQR) follow-up after the second stage was 15 (13-16) months. The median (IQR) number of previous operations was 2 (2-3). The median (IQR) length of the LMG was 3 (2.5-4) cm, and the median (IQR) width was 1 (1-2) cm. No donor-site major complications, but mild oral discomfort in the first week after graft harvesting, were reported in 39 (83%) patients. After the second stage, complications were reported in nine (19.2%) patients, meatal stenosis in five and fistula in four. The reported success rate was 80.9%.

DISCUSSION

Reconstruction of previously failed hypospadias is a challenge owing to local tissue scarring and a paucity of adjacent healthy tissue. In this study, the LMG was used in two-stage redo hypospadias repair after previous repair failure. In the present study, a success rate of 80.9% was reported after the second stage. According to this study and the published series, harvesting the LMG is associated with minimal immediate donor-site complications and no long-term morbidity. Another advantage of the LMG is easy harvesting with effortlessly reachable tongue in comparison with the buccal mucosa that is deep and requires application of a mouth retractor.

CONCLUSIONS

Two-stage LMG urethroplasty is a reliable procedure for salvage urethroplasty. Lingual mucosal graft harvesting is easy, with minor oral complications.

Penile urethral stricture disease

Patients affected by a urethral stricture account for a considerable cost to all healthcare systems. The estimated prevalence of all urethral stricture in the UK is 10/100,000 men during youth, increasing to about 40/100,000 by age 65 years and to more than 100/100,000 thereafter. A penile urethral stricture is a narrowing of the lumen of the urethra due to ischaemic fibrosis of the urethral epithelium and/or spongiofibrosis of the corpus spongiosum occurring within the penile urethra. Its aetiology is largely idiopathic but other important causes are failed hypospadias repair and lichen sclerosus, which account for 60% of all cases. Strictures of the anterior urethra account for 92% of cases: bulbar strictures are more frequent (46.9%), followed by penile (30.5%) and combined bulbar/penile (9.9%), that is, 40.4% of all men presenting with stricture will have a penile urethral stricture alone or in combination with a bulbar urethral stricture. There are several options for the treatment of penile urethral strictures ranging from less invasive treatments, including urethral dilatation and direct vision internal urethrotomy, to more complex augmentation graft and flap urethroplasty. The aim of the present review is to describe the aetiology and epidemiology of anterior urethral strictures and the available options reported in literature for their treatment.

Level of evidence: 1a

Contemporary outcomes of hypospadias retrieval surgery in adults

OBJECTIVE

To describe the surgical approach and outcomes in the treatment of adult patients with complications of childhood hypospadias surgery, as such patients present a significant reconstructive challenge due to the combination of anatomical and cosmetic deformity, which often results in major functional and psychosexual sequelae.

PATIENTS AND METHODS

We analysed prospectively collected data on 79 adults with complications of childhood hypospadias surgery, who were operated on between 2004 and 2016. Of the 79 patients, 48 underwent a two-stage urethroplasty using a buccal mucosa graft, and 31 underwent a one-stage distal urethroplasty.

RESULTS

Patients were followed up using flexible cystoscopy (every 6-9 months). The mean (range) follow-up was 48 (12-96) months. Of the 48 patients who underwent a two-stage repair, eight (16%) needed a revision of the first-stage graft. In total, nine of the 48 patients (16%) developed fistula requiring closure after the second stage; all but one was closed successfully on the first attempt, whilst one required two attempts before closure. Only two of the 48 patients that underwent a two-stage procedure required a re-do urethroplasty within 3 years. Of the 31 patients who underwent a one-stage repair, six (19%) needed fistula closure, all of which were successful. No patient required a further urethroplasty during follow-up.

CONCLUSIONS

Despite the significant surgical challenges found in this patient group, excellent long-term functional outcomes can be achieved. As expected there is a need for additional intervention, either for revision of the first stage or to close fistulae and less commonly for further reconstruction for stricture recurrence.

Rotational Advancement in Cleft Nose Rhinoplasty - Buccal Mucosal Grafts Serve as a Powerful Tool

OBJECTIVE

Our aim was to analyze our technique of a modified rotational advancement in conjunction with buccal mucosal grafts (BMGs) in a subgroup of severe cleft cases.

DESIGN

A retrospective clinical and photographic evaluation was conducted. Columella angle (CA) and tip projection (TPR) served as instruments in a photometric analysis.

SETTING

Academic university hospital and specialized craniofacial cleft center.

PATIENTS

At the time of the secondary rhinoplasty, 61 cleft patients were included, all 17 years or older.

INTERVENTIONS

Rotational advancement with usage of BMGs was performed in selected cases by a single surgeon.

MAIN OUTCOME MEASURES

Nasal symmetry and aesthetic appearance.

RESULTS

From 2003 to 2011, 29 unilateral severe cleft cases (group I) underwent a modified alar rotational advancement with BMGs. Group II, with 32 cases, represented patients without BMGs. Technique and management of BMGs were described in detail. The complication rate of donor and recipient site presented as very low. The CA was improved significantly in both groups. Also, TPR improved (not significantly) in group I. Using our technique, we considerably enhanced the aesthetic results and symmetry in secondary cleft rhinoplast.

CONCLUSIONS

Rotating the vestibular skin makes it possible to eliminate the traction of this skin on the repositioned alar cartilage, therefore achieving a more pleasing and stable nasal symmetry in secondary cleft rhinoplasty. Versatile BMGs close this gap, thus making them a powerful tool in the arsenal of the reconstructive cleft surgeon.

The hypospadias classification affected the surgical outcomes of staged oral mucosa graft urethroplasty in hypospadias reoperation: An observational study

The staged graft urethroplasty is a recommended technique for repairing complex hypospadias. This retrospective study aimed to investigate the outcomes of this technique in hypospadias patients undergoing reoperation and to analyze the underlying contributing factors including age, meatus location, and graft and suture type.We retrospectively analyzed 40 hypospadias patients undergoing reoperation who received a staged oral graft urethroplasty, including 15 buccal mucosal grafts and 25 lingual mucosal grafts. Median age at presentation was 18.5 years, and median follow-up was 17.5 months (range 8-30 months). The patients were classified according to their original meatus location.Twenty-five complications developed in 12 of 40 (30%) cases, including 6 fistulas (15%), 7 infections (17.5%), 9 cases of glans dehiscence (22.5%), and 3 cases of stenosis (7.5%). There was no significant difference in the overall complication rates between prepuberty and postpuberty groups. In addition, no significant difference in complications was found between the 2 graft techniques. The complications were significantly higher in the original perineal type compared with the original penoscrotal type (7/10 vs 5/30, P = .0031). Seven patients who originally had perineal hypospadias developed multiple complications.Based on this study, the staged graft urethroplasty is an effective technique in reoperative hypospadias repairs with reasonable complication risk. The hypospadias classification affects the surgical outcomes.

Management of the patient with failed hypospadias surgery presenting in adulthood

The management of patients who have had complications of primary surgery for the resolution of a hypospadiac deformity remains a therapeutic challenge. Adults with complications following childhood hypospadias repairs are undoubtedly a difficult population to treat, as there is usually a cosmetic deformity, lower urinary tract symptoms, and resulting psychosexual consequences. A surgeon's experience has been and still remains an important factor in determining subsequent surgical outcomes, particularly with more severe or complex cases. The purpose of this review is to evaluate the complications of hypospadias repair that present in adults and review published experience in treating them.

Lingual mucosal graft two-stage Bracka technique for redo hypospadias repair

Objectives

To report our initial experience in redo hypospadias repair with a lingual mucosal graft (LMG) using a two-stage Bracka technique.

Patients and methods

This study was prospectively conducted and included 26 patients with hypospadias with failed previous repairs. All the patients had a LMG using a two-stage Bracka technique. In the first stage, the harvested LMG, from the ventro-lateral surface of the tongue, was implanted in a well-prepared vascularised bed in the ventral aspect of the penis. After 6 months, tubularisation of the well-taken graft was completed. Tunica vaginalis or a dartos flap was used as second-layer coverage of the neourethra. Success was defined as acceptable aesthetic and functional outcomes without any additional surgical interventions.

Results

The mean (SD) patient age was 5.15 (1.6) years. The mean (SD) LMG length was 3.82 (0.9) cm and the width was 1.5 (0.5) cm. The mean (SD) number of previous repairs was 2.76 (1.1). The mean (SD) follow-up was 12 (2) months. Donor-site complications included: pain in all patients, with a pain score of >3 on the visual analogue pain scale (0–10) in 10 (38%); and speech problems in 19 (73%). First-stage complications were graft loss (n = 2) and contracture (n = 1). The second stage was completed in 23 patients resulting in the following significant complications: meatal stenosis plus fistula (n = 2), breakdown (n = 1). Successful hypospadias repair was achieved in 77% (20/26) of the patients.

Conclusion

Lingual mucosa is a reliable and versatile graft material in the armamentarium of two-stage Bracka hypospadias repair with the merits of easy harvesting and minor donor-site complications.

Use of Bipedicled Dorsal Penile Flap With Z Release Incision: A New Option in Redo Hypospadias Surgery

OBJECTIVE

To solve the challenge in redo hypospadias surgery, we tried to use a bipedicled dorsal penile flap with a Z release incision in failed hypospadias cases and reported the outcome.

MATERIALS AND METHODS

Thirty male children with 3 or 4 previous unsuccessful hypospadias surgeries were included in our study. Our technique was done after at least 6 months from the last surgery. A flap of the dorsal penile skin was preserved and the skin lateral to the flap was dissected on each side. A small opening was done in the dartos proximal to flap. The glans was withdrawn through this opening with a ventral transposition of the flap. Z-plasty was used to compensate for the deficient dorsal skin; the Z-plasty had 3 limbs and all were made of equal length.

RESULTS

The mean age of the patients was 5.4 ± 1.8 years and the mean follow-up was 2.1 ± 0.7 years. The technique was successful in 80%. Reoperation was required in 3 cases; all cases were managed using a 2-stage buccal mucosal graft. A small fistula at the coronal level developed in 2 cases but closed spontaneously within 1 month. All patients were voiding well and had a vertically oriented meatus at the tip of the glans and satisfactory cosmetic results.

CONCLUSION

Repair of failed hypospadias using a bipedicled dorsal penile skin flap with Z release incision is a safe and simple procedure offering high success rates.

Urethral reconstruction with autologous urine-derived stem cells seeded in three-dimensional porous small intestinal submucosa in a rabbit model

BACKGROUND

Urethral reconstruction is one of the great surgical challenges for urologists. A cell-based tissue-engineered urethra may be an alternative for patients who have complicated long strictures and need urethral reconstruction. Here, we demonstrated the feasibility of using autologous urine-derived stem cells (USCs) seeded on small intestinal submucosa (SIS) to repair a urethral defect in a rabbit model.

METHODS

Autologous USCs were obtained and characterized, and their capacity to differentiate into urothelial cells (UCs) and smooth muscle cells (SMCs) was tested. Then, USCs were labeled with PKH67, seeded on SIS, and transplanted to repair a urethral defect. The urethral defect model was surgically established in New Zealand white male rabbits. A ventral urethral gap was created, and the urethral mucosa was completely removed, with a mean rabbit penile urethra length of 2 cm. The urethral mucosal defect was repaired with a SIS scaffold (control group: SIS with no USCs; experimental group: autologous USC-seeded SIS; n = 12 for each group). A series of tests, including a retrograde urethrogram, histological analysis, and immunofluorescence, was undertaken 2, 3, 4, and 12 weeks after the operation to evaluate the effect of the autologous USCs on urethral reconstruction.

RESULTS

Autologous USCs could be easily collected and induced to differentiate into UCs and SMCs. In addition, the urethral caliber, speed of urothelial regeneration, content of smooth muscle, and vessel density were significantly improved in the group with autologous USC-seeded SIS. Moreover, inflammatory cell infiltration and fibrosis were found in the control group with only SIS, but not in the experimental autologous USC-seeded SIS group. Furthermore, immunofluorescence staining demonstrated that the transplanted USCs differentiated into UCs and SMCs in vivo.

CONCLUSIONS

Autologous USCs can be used as an alternative cell source for cell-based tissue engineering for urethral reconstruction.

One-stage dorsal lingual mucosal graft urethroplasty for the treatment of failed hypospadias repair

The aim of this study was to retrospectively investigate the outcomes of patients who underwent one-stage onlay or inlay urethroplasty using a lingual mucosal graft (LMG) after failed hypospadias repairs. Inclusion criteria included a history of failed hypospadias repair, insufficiency of the local skin that made a reoperation with skin flaps difficult, and necessity of an oral mucosal graft urethroplasty. Patients were excluded if they had undergone a failed hypospadias repair using the foreskin or a multistage repair urethroplasty. Between January 2008 and December 2012, 110 patients with failed hypospadias repairs were treated in our center. Of these patients, 56 underwent a one-stage onlay or inlay urethroplasty using LMG. The median age was 21.8 years (range: 4–45 years). Of the 56 patients, one-stage onlay LMG urethroplasty was performed in 42 patients (group 1), and a modified Snodgrass technique using one-stage inlay LMG urethroplasty was performed in 14 (group 2). The median LMG urethroplasty length was 5.6 ± 1.6 cm (range: 4–13 cm). The mean follow-up was 34.7 months (range: 10–58 months), and complications developed in 12 of 56 patients (21.4%), including urethrocutaneous fistulas in 7 (6 in group 1, 1 in group 2) and neourethral strictures in 5 (4 in group 1, 1 in group 2). The total success rate was 78.6%. Our survey suggests that one-stage onlay or inlay urethroplasty with LMG may be an effective option to treat the patients with less available skin after failed hypospadias repairs; LMG harvesting is easy and safe, irrespective of the patient's age.

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.

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.

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.

Which type of urethroplasty in failed hypospadias repair? An 8-year follow up

OBJECTIVE

To report our 8-year follow up for redo hypospadias repair.

METHODS

A total of 56 patients with previous failed hypospadias repair were included in our study. Patients' data were analyzed regarding age, number of previous repairs, meatal location, procedure performed, operative time and complications. Patients were followed up for 3 to 102 (mean 52) months.

RESULTS

Patient age ranged from 15 to 204 (mean 90.7) months. Forty-two patients had a single previous hypospadias repair, eleven had two previous repairs and three had four previous repairs. Of the 56 patients, 16 underwent oral mucosal graft urethroplasty, 15 onlay island flap, 14 parameatal flap, 10 tubularized incised plate urethroplasty, and 1 tubularized preputial flap. Complications were encountered in 16 (28.5%) patients in the form of graft contracture in 3, meatal stenosis in 2, urethral stricture in 2 including the patient with tubularized flap, urethra-cutaneous fistula in 7, bleeding in 1 and skin disruption in 1. The final complication rate was 25%.

CONCLUSIONS

Decision making in redo hypospadias surgery depends mainly on local tissue availability and the degree of tissue scarring. The characteristics of oral mucosal graft make it suitable for urethroplasty in the absence of local donor tissues. A long-term follow up for redo hypospadias repair is required to assess the late neourethral stricture and residual penile curvature.

The use of small intestinal submucosa graft for hypospadias repair: Pilot study

Objective

To evaluate the outcome of using commercially available (SIS) grafts for repairing hypospadias. Collagen-based acellular matrices, including SIS and bladder submucosa matrix, have been used to repair urethral strictures, with varying success, and patients with hypospadias and with inadequate or no genital skin need a substitute tissue for urethroplasty.

Patients and methods

This pilot study included 12 patients (mean age 8 years, range 1.5–15) with hypospadias (distal in six, mid-shaft in four and proximal in two). They underwent a repair with four layers of prefabricated SIS as an onlay graft. The outcome was assessed for cosmetic appearance, urinary stream and the postvoid residual volume. The chi-squared and Mann–Whitney U-tests were used to assess the relationship between preoperative factors and the outcome of the repair with SIS grafting.

Results

The mean (range) follow-up was 23 (6–36) months. Nine patients ultimately voided normally, with a good cosmetic appearance and no postvoid residual urine. Six patients had a successful repair with no further intervention, whilst three had small fistulae that were treated by simple closure. In three patients the graft failed, by complete disruption or stricture. Graft infection adversely affected the outcome of SIS grafting.

Conclusions

The prefabricated SIS graft can be used as an alternative substitute for urethral reconstruction when genital skin is insufficient or lacking, as in circumcised patients or a repeat hypospadias repair. Graft infection is the chief reason for graft failure and should be prevented. Further studies with more patients are needed to confirm these preliminary results.

[Oral mucosa for reconstructive urethral surgery]

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

Cell-seeded tubularized scaffolds for reconstruction of long urethral defects: a preclinical study

BACKGROUND

The treatment options for patients requiring repair of a long segment of the urethra are limited by the availability of autologous tissues. We previously reported that acellular collagen-based tubularized constructs seeded with cells are able to repair small urethral defects in a rabbit model.

OBJECTIVE

We explored the feasibility of engineering clinically relevant long urethras for surgical reconstruction in a canine preclinical model.

DESIGN, SETTING, AND PARTICIPANTS

Autologous bladder epithelial and smooth muscle cells from 15 male dogs were grown and seeded onto preconfigured collagen-based tubular matrices (6 cm in length). The perineal urethral segment was removed in 21 male dogs. Urethroplasties were performed with tubularized collagen scaffolds seeded with cells in 15 animals. Tubularized constructs without cells were implanted in six animals. Serial urethrography and three-dimensional computed tomography (CT) scans were performed pre- and postoperatively at 1, 3, 6, and 12 mo. The animals were euthanized at their predetermined time points (three animals at 1 mo, and four at 3, 6, and 12 mo) for analyses.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statistical analysis of CT imaging and histology was not needed.

RESULTS AND LIMITATIONS

CT urethrograms showed wide-caliber urethras without strictures in animals implanted with cell-seeded matrices. The urethral segments replaced with acellular scaffolds collapsed. Gross examination of the urethral implants seeded with cells showed normal-appearing tissue without evidence of fibrosis. Histologically, an epithelial cell layer surrounded by muscle fiber bundles was observed on the cell-seeded constructs, and cellular organization increased over time. The epithelial and smooth muscle phenotypes were confirmed using antibodies to pancytokeratins AE1/AE3 and smooth muscle-specific desmin. Formation of an epithelial cell layer occurred in the unseeded constructs, but few muscle fibers formed.

CONCLUSIONS

Cell-seeded tubularized collagen scaffolds can be used to repair long urethral defects, whereas scaffolds without cells lead to poor tissue development and strictures. This study demonstrates that long tissue-engineered tubularized urethral segments may be used for urethroplasty in patients.

Treatment of adults with complications from previous hypospadias surgery

PURPOSE

Adults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging.

MATERIALS AND METHODS

We reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment.

RESULTS

A total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50).

CONCLUSIONS

Managing problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed.

Staged buccal mucosa urethroplasty in reoperative hypospadias

Introduction:

Repeated attempts at surgical repair of serious complications involving either the partial or complete breakdown of the hypospadias repair are less likely to succeed because the penis is densely scarred, or significantly shortened, and the skin over the penis is immobile and hypovascular. Buccal mucosa (BM) has become the preferred material for reconstruction, whenever a child with skin-deficient hypospadias needs reoperation. We report the results of our surgical experience with staged reoperation using BM, in the repair of hypospadias in children with complications after multiple failed repairs.

Materials and Methods:

Children needing reoperation for hypospadias underwent a staged repair using buccal mucosa. The complications were noted.

Results:

Twenty-one children aged 3 – 16 years underwent this staged repair during the period May 2000 – April 2010. Two of these 21 children had a failed first stage. One child developed a urethro-cutaneous fistula following the second stage, which was corrected in an additional stage.

Conclusions:

The use of the buccal mucosa graft for urethral reconstruction in a child with hypospadias, needing a reoperation, is a successful method, with a low incidence of complications.

Salvage hypospadias repairs

Aim:

Review of our experience and to develop an algorithm for salvage procedures in the management of hypospadias cripples and treatment of urethral strictures following hypospadias repair.

Methods:

This is a retrospective review of hypospadias surgeries over a 41-month period. Out of a total 168 surgeries, 20 were salvage/re-operative repairs. In three children a Duplay repair was feasible, while in four others a variety of single-stage repairs could be done. The repair was staged in seven children – buccal mucosal grafts (BMGs) in five, buccal mucosal tube in one, and skin graft in one. Five children with dense strictures were managed by dorsal BMG inlay grafting in one, vascularized tunical onlay grafting on the ventrum in one, and a free tunical patch in one. Three children were treated by internal urethrotomy and stenting for four weeks with a poor outcome.

Results:

The age of children ranged from 1.5–15 years (mean 4.5). Follow-up ranged from 3 months to 3.5 years. Excellent results were obtained in 10 children (50%) with a well-surfaced erect penis and a slit-like meatus. Glans closure could not be achieved and meatus was coronal in three. Two children developed fistulae following a Duplay repair and following a staged BMG. Three repairs failed completely – a composite repair broke down, a BMG tube stenosed with a proximal leak, and a stricture recurred with loss of a ventral free tunical graft.

Conclusions:

In salvage procedures performed on hypospadias cripples, a staged repair with buccal mucosa as an inlay in the first stage followed by tubularization 4–6 months later provides good results. A simple algorithm to plan corrective surgery in failed hypospadias cases and obtain satisfactory results is devised.

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.

Mechanical stimuli-induced urothelial differentiation in a human tissue-engineered tubular genitourinary graft

BACKGROUND

A challenge in urologic tissue engineering is to obtain well-differentiated urothelium to overcome the complications related to other sources of tissues used in ureteral and urethral substitution.

OBJECTIVE

We investigated the effects of in vitro mechanical stimuli on functional and morphologic properties of a human tissue-engineered tubular genitourinary graft (TTGG).

DESIGN, SETTING, AND PARTICIPANTS

Using the self-assembly technique, we developed a TTGG composed of human dermal fibroblasts and human urothelial cells without exogenous scaffolding. Eight substitutes were subjected to dynamic flow and hydrostatic pressure for up to 2 wk compared to static conditions (n=8).

MEASUREMENTS

Stratification and cell differentiation were assessed by histology, electron microscopy, immunostaining, and uroplakin gene expression. Barrier function was determined by permeation studies with carbon 14-urea.

RESULTS AND LIMITATIONS

Dynamic conditions showed well-established stratified urothelium and basement membrane formation, whereas no stratification was observed in static culture. The first signs of cell differentiation were perceived after 7 d of perfusion and were fully expressed at day 14. Superficial cells under perfusion displayed discoidal and fusiform vesicles and positive staining for uroplakin 2, cytokeratine 20, and tight junction protein ZO-1, similar to native urothelium. Mechanical stimuli induced expression of the major uroplakin transcripts, whereas expression was low or undetectable in static culture. Permeation studies showed that mechanical constraints significantly improved the barrier function compared to static conditions (p<0.01 at 14 d, p<0.05 at 7 d) and were comparable to native urothelium.

CONCLUSIONS

Mechanical stimuli induced in vitro terminal urothelium differentiation in a human genitourinary substitute displaying morphologic and functional properties equivalent to a native urologic conduit.

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.

Outcome of proximal hypospadias repair using three different techniques

OBJECTIVE

To evaluate the outcome of proximal hypospadias repair using three different techniques.

PATIENTS AND METHODS

The study involved 194 boys with primary proximal hypospadias. The meatus was proximal penile, penoscrotal, scrotal and perineal in 98, 64, 30 and 2 patients, respectively. Tubularized incised plate (TIP) urethroplasty, onlay island flap (OIF) urethroplasty and two-stage repair were used in 96, 57 and 41 patients, respectively. Preoperative anatomical description and postoperative complications were recorded with evaluation of the final functional and cosmetic outcomes for each technique.

RESULTS

Mean age at presentation was 14.43 months (range 6-31). Mean follow-up after second stage was 32.9 months (range 11-54). Complications were encountered in 27 cases (13.9%) with no statistically significant differences between techniques; however, a significantly higher complication rate was found among patients with scrotal and perineal hypospadias and in patients with associated scrotal lesions. Urethrocutaneous fistula was the most common complication, being encountered in 7.7% of patients with a significantly higher rate among patients with scrotal hypospadias (16.7%).

CONCLUSIONS

Single-stage repair of proximal hypospadias can be successfully performed when plate preservation is possible, while two-stage repair is applicable when plate transection is necessary. Functional and cosmetic outcomes are satisfactory, with no statistically significant advantage with any technique.

Initial experience with 'inverted U' staged buccal mucosa graft (bracka) for hypospadias repair

OBJECTIVE

To describe a modification of the Bracka procedure ('inverted U'), used to enlarge the graft and diminish the risk of graft contracture compromising the subsequent urethral reconstruction.

MATERIAL AND METHODS

Inverted U Bracka procedure was performed in 10 children in whom previous hypospadias correction had failed. The surgical steps are identical to the original Bracka procedure. The only modification is reconfiguration to enlarge the graft.

RESULTS

Significant contraction of the graft was not seen in any patient and the second stage was performed uneventfully. After the second surgery there were two complications: one fistula and one wound infection.

CONCLUSION

In this preliminary study, the modification avoided significant contracture of the graft giving a more predictable size of the neourethra for the second-stage procedure. An amplified series is necessary to confirm this initial result.

Upper transverse scrotal approach for muscle- and nerve-sparing urethral stricture repair

OBJECTIVE

Open surgery on bulbar urethral strictures has become a widespread procedure. While there is inconsistency which procedure to perform at the bulbar region, there is consistency of the used incisional approach despite of several potential disadvantages. Therefore, to bypass disadvantages, we performed an upper transverse scrotal approach for stricture repair in the pendulous urethra and the distal bulbar urethra as previously reported for the placement of an artificial urinary sphincter.

METHODS

Thirteen patients (n = 13) with bulbar urethral stricture were operated by upper transverse scrotal incision approach. On five patients a free foreskin graft in dorsal onlay technique was performed. Eight patients obtained an end-to-end-anastomosis procedure. Pre- and postoperative uroflowmetry as well as retrograde urethrocystography were done. Pre- and postoperative residual postvoid urine were estimated by transabdominal ultrasound. The patients were followed-up for up to 12 months.

RESULTS

After stricture repair, Qmax improved from mean 9.0 mL/s (SD +/- 3.2) preoperatively to mean 20.3 mL/s (SD +/- 3.1), postoperatively. Postvoid residual urine decreased from mean 90.0 mL (SD +/- 68.7) to mean 41.5 mL (SD +/- 16.1). All retrograde urethrocystographies showed regular reconstructed urethral conditions.

CONCLUSION

The upper transverse scrotal incision may combine the advantages of a less traumatical approach with the excellent results of perineal approach.

Experimental use of labial mucosa free graft urinary conduit in the Mitrofanoff principle

PURPOSE

One method of treating urinary incontinence is to create a catheterizable and continent vesicostomy by the Mitrofanoff principle, based on the use of a conduit, which in the original method is the appendix. The authors present an experimental technique in which a continent vesicostomy is created by the Mitrofanoff principle, using a conduit made of a labial mucosa free graft.

METHODS

Six 30-day-old pigs underwent surgery to create a continent vesicostomy by the Mitrofanoff principle. A tube, made of labial mucosa free graft from the lower lip, was used. The labial mucosal conduit was anastomosed to the bladder mucosa. The tunnel was then prepared, part of which passed through the fibers of the right rectus muscle. The conduit was taken through the tunnel and anastomosed to the skin in the right iliac fossa.

RESULTS

Fifty days after the operation, the vesicostomy was continent, pervious, and easily catheterizable in 5 animals. In the sixth pig, the cystostomic tube did not graft successfully because it was infected.

CONCLUSIONS

A number of investigators have extrapolated Mitrofanoff method using the ileum, the ureter, or others. The use of a tube made by labial mucosa free graft is an easily performed technique, and as with the Mitrofanoff method, continence and easy catheterization are successfully achieved.

The oral mucosa graft: a systematic review

PURPOSE

We provide the reader with a critical, nonbiased, systematic review of current and precedent literature regarding the use of oral mucosa in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias.

MATERIALS AND METHODS

We reviewed pertinent English literature from January 1966 through August 1, 2006 via the databases MEDLINE/PubMed, the Cochrane Library, and EMBASE Drugs and Pharmacology regarding the use of oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias. Bibliographies of pertinent articles were explored for additional important literature.

RESULTS

Data were stratified among studies that only used oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with stricture, and those that used oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with hypospadias/epispadias. Recipient site success in the reconstruction of defects associated with stricture was significantly associated with the location of graft placement (ventral vs dorsal, p <0.001) when an onlay graft was used. Hypospadias/epispadias recipient site success was significantly associated with the type of graft used (tube vs onlay, p <0.001), and by the site of oral mucosa harvest (labial vs buccal, p <0.001). Other perioperative and patient oriented variables were not significantly associated with success at the recipient site.

CONCLUSIONS

The oral mucosa is a viable source of donor tissue displaying many characteristics of the ideal urethral graft. There are numerous variations of the oral mucosa graft urethroplasty technique. Herein comparisons are made.

Long-term outcome following hypospadias repair

Hypospadias is a common problem affecting approximately one boy in 300; it is usually corrected in the first few years of life. While early outcome data is widely available, little has been reported on the long-term problems that these men suffer. Data suggest that the majority of men have no lasting effects, but up to 40% with severe hypospadias can have some degree of voiding problems. In addition, sexual problems affecting erection, ejaculation and sexual sensation have now been reported in more than 20% of men, although these studies are few and contain only a small number of patients. This limited available data support the need for further long-term studies especially focusing on the more modern techniques.

Failed hypospadias repair presenting in adults

OBJECTIVES

To evaluate the results of one-stage and multistage urethroplasty in adults with complications following multiple failed hypospadias repairs.

METHODS

Sixty adults underwent reconstructive surgery of the following complications after hypospadias repair: stricture (34), residual hypospadias (26), fistula (18), meatal stenosis (11), penile curvature (9), hair (4), diverticula (2), and stone (1). A total of 36% of the patients had one complication and 64% had two or more complications. Twenty-nine patients underwent one-stage repair with buccal or skin grafts or direct repair, and 31 underwent multistage repairs with buccal or skin grafts.

RESULTS

Mean follow-up was 33.8 mo. Of the 60 cases, 45 (75%) had a final successful outcome and 15 (25%) failed. One-stage repair provided 24 (82.7%) successes and 5 (17.3%) failures. Multistage repair provided 21 (67.7%) successes and 10 (32.3%) failures. Buccal mucosa grafts provided 81% of success in one-stage procedures and 82.3% in multistage procedures. Penile skin grafts provided 80% of success in one-stage procedures and 50% in multistage procedures.

CONCLUSIONS

Adults with complications following childhood hypospadias repair are still a difficult population to treat with a high failure rate for reoperative surgery.