Current Trends in the Use of Buccal Grafts during Urethroplasty Among Society of Genitourinary Reconstructive Surgeons

OBJECTIVES

To analyze current standards in urethroplasty by urologists employing buccal mucosal grafts (BMG) for treating urethral stricture disease (USD).

METHODS

An IRB-approved online survey was distributed to members of the Society of Genitourinary Reconstructive Surgeons (GURS) between July and October 2022 to assess BMG utilization in urethroplasty. Questions covered surgeon experience, graft harvest site, graft length, surgical technique, and perceived success rates.

RESULTS

Of 350 invited GURS members, 134 responded (38%). 69% were GURS fellowship-trained, performing 10-30 urethroplasties annually. 95% harvested their own grafts, with 99% preferring buccal mucosa as the primary site. Buccal mucosa was favored over fasciocutaneous flap for penile urethroplasty, regardless of circumcision status (95% with, 84% without). For bulbar urethroplasty with BMG, dorsal graft placement was favored (66%) over ventral (34%). Most surgeons (90%) preferred multiple BMGs over combined graft/flap for panurethral strictures. When harvesting long grafts, 56% preferred using both cheeks. Anastomotic urethroplasty was preferred over buccal graft urethroplasty for short bulbomembranous stenosis post-radiotherapy (63% vs. 37%). Surgeons reported a success rate of 80-90% (53%).

CONCLUSIONS

The expanded scope of reconstructive urology has led to increased use of BMG in diverse urethral reconstructions. Buccal grafts are now preferred for penile, bulbar, and panurethral strictures, demonstrating high perceived success rates in the reconstructive community.

The Regenerative Microenvironment of the Tissue Engineering for Urethral Strictures

Urethral stricture caused by various reasons has threatened the quality of life of patients for decades. Traditional reconstruction methods, especially for long-segment injuries, have shown poor outcomes in treating urethral strictures. Tissue engineering for urethral regeneration is an emerging concept in which special designed scaffolds and seed cells are used to promote local urethral regeneration. The scaffolds, seed cells, various factors and the host interact with each other and form the regenerative microenvironment. Among the various interactions involved, vascularization and fibrosis are the most important biological processes during urethral regeneration. Mesenchymal stem cells and induced pluripotent stem cells play special roles in stricture repair and facilitate long-segment urethral regeneration, but they may also induce carcinogenesis and genomic instability during reconstruction. Nevertheless, current technologies, such as genetic engineering, molecular imaging, and exosome extraction, provide us with opportunities to manage seed cell-related regenerative risks. In this review, we described the interactions among seed cells, scaffolds, factors and the host within the regenerative microenvironment, which may help in determining the exact molecular mechanisms involved in urethral stricture regeneration and promoting clinical trials and the application of urethral tissue engineering in patients suffering from urethral stricture.

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.

Urethroplasty Outcomes for Pars Fixa Urethral Strictures Following Gender-affirming Phalloplasty and Metoidioplasty: A Retrospective Study

OBJECTIVE

To evaluate outcomes of three urethroplasty techniques for pars fixa (PF) urethral strictures and provide a treatment algorithm based on stricture characteristics. The PF is an essential anatomic region of the neourethra created in gender-affirming phalloplasty and metoidioplasty. Urethral strictures in this region present a reparative challenge given its unique anatomy and vascularization.

METHODS

A total of 41 urethroplasties performed on 41 patients between March 2018 and June 2021 were reviewed at two surgical centers. A Heineke-Mikulicz (HM) repair was done for strictures under 20 mm when the proximal and distal urethral segments were mobile and supported a tension-free closure. Substitution urethroplasty with ventral onlay buccal mucosal graft was utilized for strictures under 40 mm not suitable for HM repair. Complex or long (≥40 mm) strictures were treated by two-stage Johansen urethroplasty. Success of each surgical approach was defined by a minimum of 12-month follow-up without the need for a repeat intervention.

RESULTS

Mean follow-up was 30.2 months (range: 12.4-52.0 months). Mean stricture length was 16.9 mm (range: 2-55 mm). Most strictures (46%) were located at the distal PF. HM urethroplasty had a success rate of 44% (n = 16). Substitution urethroplasty had a success rate of 92% (n = 13). Two-stage Johansen urethroplasty had a success rate of 75% (n = 12).

CONCLUSION

The success rates of PF urethral stricture repair ranged from 44% to 92% depending on the surgical approach, and the best reparative procedure depends on stricture length, severity, and local tissue mobility.

Management and outcomes of urethral stricture: single centre experience over 13 years

AIM

To present a comprehensive summary of the diagnosis, treatment and follow-up process of patients who underwent open urethroplasty in our tertiary referral center for the treatment of urethral stricture in the last 13 years.

MATERIALS AND METHODS

Two hundred and forty-five (245) patients who underwent open urethroplasty between January 2008 and June 2021 were retrospectively analysed. Detailed history, physical examination, uroflowmetry, retrograde urethrography and/or voiding cystourethrography and/or urethroscopy were used throughout the preoperative diagnosis process. While evaluating the postoperative patency rates, the absence of preoperative voiding symptoms after the operation and Qmax 15 ml/sec and above were taken into account.

RESULTS

Mean stricture length was 3.8 +/- 1.4 cm. Transurethral endoscopic interventions in 79 patients (32.2%), catheterisation in 55 patients (22.4%), trauma in 54 patients (22%), infection in 15 patients (6.2%), and idiopathology in 42 patients (17.2%) were the causes for the stricture. Buccal mucosal graft was used in 125 patients (51%), penile skin flap in 32 patients (13%), end-to-end anastomosis in 83 patients (33.8%) and Heineke-Mikulicz technique in 5 patients (2%). Mean follow-up period was 67.1 +/- 28.9 months. Success rates of patients were 84% (105) in buccal mucosal graft, 78.1% (25) in penile skin flap, 86.7% (72) with end-to-end anastomosis and 80% (4) with Heineke-Mikulicz technique.

CONCLUSION

Among treatment options for urethral stricture, urethroplasty techniques is the most successful treatment. Consideration of the factors leading to the formation of the stricture, with the intraoperative findings and surgical experience will maximize the benefit the patient receives.

Mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty: a ventral modification for obliterative strictures

OBJECTIVES

To present a surgical modification for the repair of bulbar urethral strictures containing short, highly obliterative segments and report on long-term objective and patient-reported outcomes.

PATIENTS AND METHODS

We considered patients undergoing bulbar buccal mucosal graft urethroplasty (BMGU) between July 2016 and December 2019. Eligibility criteria for mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty were strictures of ≥2 cm with an obliterative segment of ≤1.5 cm. The stricture is approached ventrally to avoid extensive dissection and mobilisation. Dorsally, the scar is superficially excised and the spongiosum is left intact. Dorsal mucomucosal anastomosis is complemented by ventral onlay graft. Perioperative characteristics were prospectively collected including uroflowmetry data and validated patient-reported outcome measures on voiding, erectile, and continence function. We evaluated functional follow-up, incorporating patient-reported (lower urinary tract symptoms [LUTS] score) and functional success. Recurrence was defined as need of re-treatment.

RESULTS

Of 641 men treated with anterior BMGU, 54 (8.4%) underwent MANTA urethroplasty. Overall, 26 (48%) and 45 (83%) had a history of dilatation and urethrotomy, respectively, and 14 (26%) were redo cases. Location was bulbar in 38 (70%) and penobulbar in 16 patients (30%), and the mean (SD) graft length was 4.5 (1.4) cm. At a median (interquartile range) follow-up of 41 (27-53) months, the functional success rate was 93%. Whereas the median LUTS score significantly improved from baseline to postoperatively (13 vs 3.5; P < 0.001), there was no change in erectile function (median International Index of Erectile Function - erectile function domain score 27 vs 24) or urinary continence (median International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form sum score 0 vs 0; all P ≥ 0.4). All patients were 'satisfied' (27%) or 'very satisfied' (73%) with the outcome of their operation.

CONCLUSION

With excellent long-term objective and patient-reported outcomes, MANTA urethroplasty adds to the armamentarium for long bulbar strictures with a short obliterative segment.

Circular Penile Skin Fasciocutaneous Ventral Onlay Flap Urethroplasty as an Alternative to Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Complex Long-Segment Urethral Stricture: A Retrospective Study

Background A urethral stricture is the narrowing of the urethra that results in symptoms of obstruction. It can appear anywhere along the male urethra's length and has a variety of causes. The circular penile fasciocutaneous flap is employed in the successful single-stage reconstruction of long-segment complex anterior urethral strictures especially when the buccal mucosa is unavailable due to various reasons. The study has tried to identify a surgical technique that is more beneficial for the treatment of urethral strictures. Objective The objective of this research was to evaluate the outcomes of circular penile skin fasciocutaneous ventral onlay flap urethroplasty (group A) and the outcomes of dorsal onlay buccal mucosal graft urethroplasty (group B) in the management of complex long-segment penile urethral stricture. Methods In this retrospective study between December 2012 and December 2022, 60 patients with long-segment complex penile urethral stricture who underwent urethroplasty at our center were evaluated. Patients were divided into two groups according to the flap used (dorsal onlay buccal mucosal graft urethroplasty was used in 30 patients (group B), and circular penile fasciocutaneous flap (single stage) was used in 30 patients (group A)). The success rate and the mean peak flow rate were also calculated post-operation to identify the effectiveness of the surgical procedure used for urethral strictures. Results The study consisted of 60 patients in total. Group A's mean age was determined to be 51.2±16.2 years, whereas group B's mean age was determined to be 40.7±16.8 years. Preoperatively, the median urethral stricture length was 69 mm in group A (range: 20-100 mm) and 56 mm in group B (range: 30-110 mm). The intraoperative median length of the urethral stricture was 82 mm in group A (range: 20-120 mm) and 65 mm in group B (range: 40-140 mm). The mean peak flow rate was 30.9±6.8 mL/s in group A compared to 18.1±4.9 mL/s in group B. The success rate for group A was 89.7%, while the success rate for group B was 75.9%. Conclusion For complex long-segment urethral strictures, circular penile skin fasciocutaneous ventral onlay flap urethroplasty has a higher rate of success and fewer complications than dorsal onlay buccal mucosal graft urethroplasty. Along with success rate, it has a better mean peak flow rate and lower complications.

An insight of pathological anatomy of urethral stricture and surgical manipulations for children suffered from hypospadias

BACKGROUND

Manipulation of urethral stricture is difficult and challenging. Accurate analysis and evaluation of the pathological circumstances of narrowed urethra and surrounding tissues were important for cure. The detailed descriptions of anatomic pathology of urethral stricture are rare. An insight of the pathological anatomy of the strictured urethra and the corresponding corrections is essential for an ultimate cure. The aim of the study is to interpret the pathological anatomies of the strictured urethra and the corresponding surgical manipulations.

METHODS

From April 2007 to April 2020, eight boys who suffered from postoperative urethral stricture for hypospadias correction were studied retrospectively. The pathological anatomies of the strictured urethra were described and the corresponding surgical manipulations were analyzed.

RESULTS

All eight patients were eventually cured through surgery. The patient age was 2.58-11 years old (mean value of 4.73). The therapeutic duration was 12-130 months (mean value of 47.75). The surgical manipulation was 1-9 times (mean value of 4.5). Curative follow-up was 8-138 months (mean value of 77.75). They were all applied with flap tubularization for their primary urethroplasty.

CONCLUSIONS

Based on the principal contradiction of the pathological anatomies of the urethral stricture, one-stage or staged surgical manipulations can be applied. After stricture was resolved, refining techniques of Mathieu, TIP, modified Duckett, glanular reconstruction and et al. can be used. Although it was tiring, utilizing the ventral or dorsal penile flap with relatively good blood supply and flexibility to reconstruct the urethra is possible and successful. To reconstruct an anatomically normal urethral tract should be pursued in the primary and consequential procedures for hypospadias and urethral stricture.

Histologic Analysis of Buccal Graft Quality Stratified by Tobacco Use in Patients Undergoing Substitution Urethroplasty

OBJECTIVE

To determine if there are histologic differences relative to tobacco exposure in buccal mucosa. Substitution urethroplasty outcomes may be worse in tobacco users and we investigate if the buccal graft is inherently damaged due to chronic tobacco exposure.

METHODS

Subjects undergoing substitution urethroplasty with buccal graft harvest were prospectively consented in this IRB approved study. Subjects with poor dentition were excluded. A detailed tobacco use history was obtained. Cotinine testing was performed day of surgery to confirm or exclude active tobacco use. Trimmed portions of harvested graft were sent for tissue processing. Standard hematoxylin and eosin staining was performed. A single blinded pathologist performed analysis of the slides. Using a scale of none, mild, moderate, or severe slides were analyzed for cytologic atypia, architectural complexity, inflammation, and keratinization. Evidence of vascular damage was noted and the type of inflammation if present was classified.

RESULTS

Twenty-five buccal grafts were analyzed. No evidence of vascular damage or cytologic atypia were noted in any grafts. While mild architectural complexity and mild inflammation, typically lymphocytic, were noted in several of the buccal mucosa sections, this did not appear to correlate with tobacco exposure. The majority of grafts demonstrating increased keratinization correlated with significant tobacco exposure, but this was not consistently noted in all those with tobacco use.

CONCLUSIONS

Buccal mucosa in patients with tobacco exposure did not show significant histologic alterations. Outcomes of substitution urethroplasty may be more impacted by persistent systemic exposure causing local ischemia as opposed to the graft tissue itself.

Laparoscopic ureteroplasty with oral mucosal graft for ureteral stricture: Initial experience of eighteen patients

OBJECTIVE

To investigate the feasibility and clinical efficacy of laparoscopic ureteroplasty with oral mucosal graft for ureteral stricture and describe the initial experience of eighteen operations.

METHODS

A retrospective analysis was performed on the clinical data of 18 patients who underwent laparoscopic ureteroplasty with oral mucosal graft for long segment or complex ureteral stricture admitted to the Second Affiliated Hospital of Anhui Medical University from July 2018 to June 2021. After the stricture ureter segment was freed during the operation, the ureteral stenosis segment was longitudinally cut. The required oral mucosa is removed according to the length of the stenosis. Oral mucosal grafts were harvested and placed in the ureter as an anterior onlay with omental wrapping.

RESULTS

Ureteral repair was performed laparoscopically in all cases, with no conversion to open surgery and no serious complications. The median length of ureteral stenosis was 3 cm (range, 2-7 cm), the mean operative time was 205.8 ± 33.4 min, indwelling time of the drainage tube was 4.9 ± 1.6 days, and the median length of postoperative stay was 7 days (range, 4-14 days). The double J tube was removed three to six weeks postoperatively. One of the eighteen patients had restenosis after surgery, and the other patients showed no deterioration of the severity of the obstructive uropathy after follow-up imaging examination.

CONCLUSION

Laparosopic ureteroplasty with oral mucosal graft is a simple, safe and efficient option for the treatment of ureteral stricture. Although the results of the initial experience are encouraging, a large cohort study with longer follow-up period is need to be done.

Outcomes and predictive factors for re-stricture with urethroplasty methods for anterior urethra stricture

OBJECTIVES

We wished to compare the treatment success of urethroplasty methods (EPA and BMG) used for anterior urethra stricture after unsuccessful internal urethrotomy.

METHODS

A total of 85 and 51 patients, respectively, who underwent excision and primary anastomosis (EPA) and buccal mucosal graft (BMG) urethroplasty due to recurrent strictures after direct vision internal urethrotomy (DVIU) were evaluated retrospectively. On the uroflowmetry test, >15 ml/s urine flow and residual urine (PVR) below 50 ml were determined as success criteria. Cox regression analysis investigated the probable predictive factors for surgery success. Kaplan-Meier analysis assessed stricture free survival after redo-urethroplasty.

RESULTS

After surgery, EPA and BMG patients were followed for 31.9 ± 9.8 (4-40) and 30.7 ± 10.3 (4-40) months. At the end of this follow-up duration, success was obtained for 71 (83.5%) and 44 (86.3%) patients. Mean re-stricture times were 13.9 ± 6.0 (4-19) and 10.2 ± 5.1 (4-26) months. Most re-strictures had penile location (10 (71.5%) and 7 (100%)). After one session of DVIU, there was 100% success in both groups, but after >3 sessions of DVIU, success fell to 70.3% and 78.3% in the groups respectively. Patients with high numbers of DVIU sessions had longer durations for urethroplasty surgery. Apart from complications related to the donor field in the oral region with BMG and four patients who developed fistula (7.8%), complications were similar in both groups.

CONCLUSIONS

In this series of cases, it was not possible to identify which of the techniques employed provides the best result or predictive factors for stenosis recurrence after correction procedures for anterior urethral stenosis.

How to do a penile urethroplasty using a novel self-retaining penile retractor

Effective retraction and clear exposure of urethral tissue is essential in reconstructive penile surgery. The Joshi-Kulkarni retractor provides stable, bloodless operative exposure via non-traumatic tissue compression at the base of penis. The self-retaining design of this retractor also improves ergonomics thereby reducing surgeon fatigue. In this article, we describe how to do a penile urethroplasty by using the Joshi-Kulkarni penile retractor.

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.

Sources, Selection, and Microenvironmental Preconditioning of Cells for Urethral Tissue Engineering

Urethral stricture is a common urinary tract disorder in men that can be caused by iatrogenic causes, trauma, inflammation, or infection and often requires reconstructive surgery. The current therapeutic approach for complex urethral strictures usually involves reconstruction with autologous tissue from the oral mucosa. With the goal of overcoming the lack of sufficient autologous tissue and donor site morbidity, research over the past two decades has focused on cell-based tissue-engineered substitutes. While the main focus has been on autologous cells from the penile tissue, bladder, and oral cavity, stem cells from sources such as adipose tissue and urine are competing candidates for future urethral regeneration due to their ease of collection, high proliferative capacity, maturation potential, and paracrine function. This review addresses the sources, advantages, and limitations of cells for tissue engineering in the urethra and discusses recent approaches to improve cell survival, growth, and differentiation by mimicking the mechanical and biophysical properties of the extracellular environment.

Identification of a novel homozygous LAMB3 mutation in a Chinese male with junctional epidermolysis bullosa and severe urethra stenosis: A case report

Introduction: Epidermolysis bullosa (EB) is a skin fragility disorder that is caused by molecular aberrations in the epidermal basement membrane zone. Based primarily on the cleavage plane within the skin, EB is classified into four major subtypes: EB simplex; junctional EB (JEB); dystrophic EB; and Kindler EB. The junctional form (JEB) can lead to blistering and a variety of extracutaneous complications, including genitourinary tract involvement. Despite therapeutic progress, treatment modalities for urological complications of JEB are currently limited.

Results: We present the case of a Chinese male with intermediate JEB and profound urinary tract stenosis. Due to the progression of the urinary tract stenosis, he presented with repeated urological symptoms, such as high frequency of urination, painful urination, and difficult voiding. After birth, multiple blisters on the fingers, feet, and limbs, as well as nail dystrophies and spare hair were noted. Mutation analysis revealed that the patient carried a homozygous frameshift mutation in the LAMB3 gene [c.1172_1179delinsTGTGTGTGCAAGGAG/p. (P391Lfs*23)]. After receiving treatment for urethral dilatation, lingual mucosa for anterior urethroplasty, and repair of urethral stricture using a ventral onlay penile skin flap, the patient still experienced a relapse of urinary tract stenosis. Finally, the patient underwent perineal urethrostomy. In contrast, his older brother with similar urological symptoms received regular urethral dilatation, and the curative effect was positive.

Conclusion: Here we report on a case with a novel LAMB3 mutation that led to JEB with profound urinary tract stenosis, which has expanded our experience in the treatment of EB urological complications.

Bilateral T-shaped Scrotoplasty as an Ancillary Technique of Staged Anterior Urethroplasty: The End Justifies the Means

Staged urethroplasty is performed to treat long-segment obliterating anterior urethral strictures. The technique is particularly challenging when the penobulbar junction is involved, as it requires the transection of the scrotum and the formation of lateral testicular fans. To date, there is no established surgical protocol for this ancillary technique in large volume scrotums with excess skin. We report a case of staged urethroplasty with the necessity of performing T-scrotoplasty due to bulky scrotum. After six months, the T-plasty was successfully resolved, and a new scrotum was formed from the two hemiscrota. In conclusion, scrotoplasty using a bilateral T-plasty is an excellent technique to overcome the necessity of splitting the scrotum by externalizing the urethra to allow for excellent buccal mucosal graft healing over a period of six months. The two separate testicular fans can be reapproximated along the raphe after re-tubularizing the urethra in the 2nd stage, shaping a new scrotum with satisfactory cosmetic results.

Recent Trends and Advances in Anterior Urethroplasty

While patient preference often helps guide treatment decisions, poor long-term success combined with cumulative risk of repeat endoscopic treatments and the complications innately associated with urethral stricture emphasize that urethroplasty is most often the best choice for successful treatment in the long-term. This has led to the need to better refine urethroplasty techniques and optimize patient outcomes. Urethroplasty has now largely transitioned to a day-surgery procedure in the majority of centers. Some evidence suggests that avoiding urethral transection and/or avoiding overzealous urethral mobilization may lead to a reduction in post-operative sexual dysfunction. The trend toward single stage penile urethroplasty with buccal mucosal grafts likely minimizes patient morbidity without compromising urethroplasty success. For urethroplasty success to further improve particularly in patients at high risk for stricture recurrence, the synergistic potential of combining wound healing enhancing agents with evolving tissue-engineering represents an exciting future opportunity in the quest to perfect urethroplasty outcomes.

Onlay Pedicled Transverse Skin Flap versus One-Stage Inlay Buccal Mucosal Graft in Penile Urethroplasty: A Prospective Matched-Pair Analysis

INTRODUCTION

The aim of this study was to compare urethroplasty using onlay pedicled transverse skin flap (PSF) versus one-stage inlay buccal mucosa graft (BMG) in repair of penile urethral strictures.

METHODS

We conducted a prospective matched-pair analysis of 44 male patients receiving penile urethroplasty between June 2016 and June 2019. There were 22 patients who received PSF and 22 patients who received BMG. Matching was performed according to stricture length. Patients with strictures caused by lichen sclerosus, prior hypospadias repair, or failed prior urethroplasty were excluded. Treatment was considered successful if no recurrence was observed. Successful repair, complication rates, patients' satisfaction, and quality of life improvement were endpoints of this study.

RESULTS

Mean follow-up was 40.3 months. PSF and BMG showed comparable success rates (90.9% vs. 86.4%, p = 0.713). Recurrent stricture occurred in 2 patients (9.1%) who received PSF and in 3 patients (13.6%) who received BMG. Operation time was significantly longer for PSF than for BMG (108.4 min vs. 78.1 min, p = 0.01). Univariable logistic regression analysis revealed no relevant risk factors for stricture recurrence.

CONCLUSION

Early results indicate comparable success rates of PSF and BMG in penile urethroplasty. Further studies with larger sample size and longer follow-up periods are required to evaluate subtle differences between both techniques.

Periurethral Abscess Following Urethral Reconstruction: Clinical Features and Prognosis

OBJECTIVES

To evaluate the clinical and prognostic details of periurethral abscess (PUA) formation following urethroplasty (UP).

METHODS

A retrospective review was performed to identify men who developed PUA after UP between 2007 and 2019 at a single tertiary care referral center. Patient demographics, stricture characteristics, and UP technique were recorded. Outcomes included time to PUA, presenting symptoms, wound cultures, imaging, and ultimate management. Comparative analysis between PUA and non-PUA patients was performed using Fisher's Exact test and Student's t-test.

RESULTS

Among 1499 UP cases, 9 (0.6%) developed PUA. Mean stricture length was 4.6 cm with most located in the bulbar urethra (5/9, 56%), while 4/9 (44%) had undergone prior UP. PUA rates were 7/288 (2.4%) and 2/815 (0.3%) for substitution and anastomotic UP respectively. Voiding cystourethrogram (VCUG) demonstrated extravasation in 67% (4/6) of available UP cases imaged. Subsequent VCUG confirmed leak improvement or resolution in all cases. Wound cultures were frequently polymicrobial (4/6, 67%). Management included antibiotics with (6/9) and without (3/9) incision and drainage (I/D). Urinary drainage was performed in 5 patients using suprapubic tube (3/5) and foley placement (2/5). PUA resolution was observed in all patients while stricture symptom recurrence was observed in 2/9 (22%) patients with mean time to recurrence of 15 months. Overall mean follow-up time was 22 months.

CONCLUSION

PUA is a rare complication of UP that may be more common in setting of postoperative urine leak. PUA is safely managed with I/D, urethral rest, and antibiotics, with low risk of recurrent stricture formation thereafter.

Oral Mucosa vs. Penile Skin Flap in Substitution Urethroplasty for Anterior Urethral Strictures: A Systematic Review and Meta-Analysis

Background: The purpose of this study is to compare the effectiveness and safety of oral mucosa and penile skin flaps in the treatment of anterior urethral stricture. Methods: This meta-analysis was carried out according to the principle of preferred reporting items for systematic reviews and meta-analysis (PRISMA) and registered at PROSPERO (CRD42021277688). The Cochrane Library, PubMed, Embase, CKNI databases were searched and reviewed up to Sep 2021. Quality evaluation was performed with Newcastle-Ottawa Scale (NOS) system for non-randomized studies and Cochrane stools for randomized studies. Data synthesis was conducted with RevMan 5.4 software (Cochrane) and a Stata 15.0 environment (Stata Corpor, College Station, TX, USA). Results: After the research screening, eight studies (comprising 445 patients) were finally included in the quantitative analysis. In the success rate comparison, there was no significant difference between oral mucosa and penile skin flaps (oral mucosa vs. penile skin flap, Mantel-Haenszel statistic [M-H] fixed model, OR: 0.80, 95% CI: 0.47-1.34, P = 0.39). There was no significant difference in the post-operative complication comparison (oral mucosa vs. penile skin flap, Mantel-Haenszel statistic [M-H] fixed model, OR: 0.68, 95% CI: 0.40-1.16, P = 0.15). However, considering that the site of oral mucosa is far from the anterior urethra, it may have advantages in operation time through simultaneous operations (oral mucosa vs. penile skin flap, MD: -40.05, 95% CI: -79.42, -0.68, P = 0.046). Conclusion: When the oral mucosal graft was used in the anterior urethra urethroplasty, it had a similar success rate and post-operative complication rate, and oral mucosa substitution had a shorter operation time. This evidence-based medical research further supports the view that oral mucosa is the preferred substitution material for the anterior urethra urethroplasty.

Analysis of the Physico-Chemical, Mechanical and Biological Properties of Crosslinked Type-I Collagen from Horse Tendon: Towards the Development of Ideal Scaffolding Material for Urethral Regeneration

Urethral stenosis is a pathological condition that consists in the narrowing of the urethral lumen because of the formation of scar tissue. Unfortunately, none of the current surgical approaches represent an optimal solution because of the high stricture recurrence rate. In this context, we preliminarily explored the potential of an insoluble type-I collagen from horse tendon as scaffolding material for the development of innovative devices for the regeneration of injured urethral tracts. Non-porous collagen-based substrates were produced and optimized, in terms of crosslinking density of the macromolecular structure, to either provide mechanical properties compliant with the urinary tract physiological stress and better sustain tissue regeneration. The effect of the adopted crosslinking strategy on the protein integrity and on the substrate physical-chemical, mechanical and biological properties was investigated in comparison with a decellularized matrix from porcine small intestinal submucosa (SIS patch), an extensively used xenograft licensed for clinical use in urology. The optimized production protocols allowed the preservation of the type I collagen native structure and the realization of a substrate with appealing end-use properties. The biological response, preliminarily investigated by immunofluorescence experiments on human adult renal stem/progenitor cells until 28 days, showed the formation of a stem-cell monolayer within 14 days and the onset of spheroids within 28 days. These results suggested the great potential of the collagen-based material for the development of scaffolds for urethral plate regeneration and for in vitro cellular studies.

Impact of urethroplasty on overactive bladder symptoms in patients with anterior urethral strictures

OBJECTIVES

To investigate the incidence of overactive bladder in men with anterior urethral stricture and to evaluate the impact of urethroplasty on its improvement.

METHODS

A total of 104 men with anterior urethral stricture who underwent urethroplasty between 2016 and 2020 completed a validated urethral stricture surgery patient-reported outcome measure comprising six lower urinary tract symptoms questions on voiding symptoms and overactive bladder symptom score before and 3, 6, and 12 months after urethroplasty. Patients with an urgency score of ≥2 for overactive bladder symptom score question 3, and a total overactive bladder symptom score of ≥3 were considered to have overactive bladder. An improvement in overactive bladder was defined as a decrease in the total overactive bladder symptom score by at least three points.

RESULTS

Thirty-nine patients (37.5%) were considered to have overactive bladder, and improvement in overactive bladder after urethroplasty was found in 30 (76.9%). Maximum flow rate on uroflowmetry, postvoid residual urine volume, lower urinary tract symptoms total score, and total overactive bladder symptom score were all significantly improved after urethroplasty (P < 0.0001 for all variables). There was a positive correlation between changes in lower urinary tract symptoms total score and total overactive bladder symptom score (Spearman's correlation 0.48, P < 0.0001). Multivariate logistic regression analysis showed that greater change in lower urinary tract symptoms score was an independent predictor of improvement in overactive bladder (odds ratio 1.30, 95% confidence interval 1.06-1.59; P = 0.002).

CONCLUSIONS

Overactive bladder is prevalent in patients with anterior urethral stricture, and can be effectively improved after urethroplasty. Improvement of voiding symptoms are key for improving overactive bladder symptoms.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Scarless Healing Tale: Comparing Homeostasis and Wound Healing of Oral Mucosa With Skin and Oesophagus

Epithelial tissues are the most rapidly dividing tissues in the body, holding a natural ability for renewal and regeneration. This ability is crucial for survival as epithelia are essential to provide the ultimate barrier against the external environment, protecting the underlying tissues. Tissue stem and progenitor cells are responsible for self-renewal and repair during homeostasis and following injury. Upon wounding, epithelial tissues undergo different phases of haemostasis, inflammation, proliferation and remodelling, often resulting in fibrosis and scarring. In this review, we explore the phenotypic differences between the skin, the oesophagus and the oral mucosa. We discuss the plasticity of these epithelial stem cells and contribution of different fibroblast subpopulations for tissue regeneration and wound healing. While these epithelial tissues share global mechanisms of stem cell behaviour for tissue renewal and regeneration, the oral mucosa is known for its outstanding healing potential with minimal scarring. We aim to provide an updated review of recent studies that combined cell therapy with bioengineering exporting the unique scarless properties of the oral mucosa to improve skin and oesophageal wound healing and to reduce fibrotic tissue formation. These advances open new avenues toward the ultimate goal of achieving scarless wound healing.

The Expanding Use of Buccal Mucosal Grafts in Urologic Surgery

The advent and success of buccal mucosal grafts as a substitution material in the urinary tract has changed the landscape of reconstructive urology. Due to its ease to harvest, low morbidity, and advantageous properties, there has been a growing number of applications for buccal mucosal grafts in upper and lower urinary tract reconstruction as well as genital reconstruction. In this article, we review the historical application and the evolution of buccal mucosal grafts and provide an up-to-date review on its utilization in urologic procedures.

Triangular extension of hinge flaps: A novel technique to resolve stomal stenosis and prevent restenosis in staged buccal mucosal urethroplasty

OBJECTIVES

To verify the utility of triangular extension of a hinge flap in buccal mucosal staged urethroplasty to resolve stomal stenosis after the first stage and ultimately prevent restenosis.

METHODS

A total of 23 patients (triangular extension group) were studied in 2013-2019. In the first stage, buccal mucosa was transplanted, and an extended triangle portion of the mucosa was placed beside the proximal and/or distal stoma that was created when the stricture segment of the urethra was resected. In the second stage, during tubularization of the urethral plate, an incision was made at the stoma to increase the caliber to which the triangular extension was inserted. The procedure was considered successful when a 17-Fr flexible cystoscope passed through the reconstructed urethra at 6 months after the second-stage urethroplasty and no additional surgery or bougie dilation required. The clinical course of the triangular extension group was compared with 24 patients who underwent conventional staged urethroplasty (control group).

RESULTS

In total, 20 patients from each group underwent second-stage surgery. No patients in the triangular extension group required additional revision surgery because of stomal stenosis after first-stage surgery, whereas five (20%) control patients did. Urethroplasty was successful in 19 patients (95%) in the triangular extension group and in 19 patients (95%) in the control group. Uroflowmetry after the second-stage surgery indicated that the mean maximum urinary flow rate was 21.5 and 15.8 mL/s after triangular extension and the control procedure, respectively (P = 0.027).

CONCLUSIONS

The triangular extension technique reduces the need for revision surgery and prevents postoperative restenosis.

Fabrication of Adipose-Derived Stem Cell-Based Self-Assembled Scaffold under Hypoxia and Mechanical Stimulation for Urethral Tissue Engineering

Long urethral strictures are often treated with autologous genital skin and buccal mucosa grafts; however, risk of hair ingrowth and donor site morbidity, restrict their application. To overcome this, we introduced a tissue-engineered human urethra comprising adipose-derived stem cell (ASC)-based self-assembled scaffold, human urothelial cells (UCs) and smooth muscle cells (SMCs). ASCs were cultured with ascorbic acid to stimulate extracellular matrix (ECM) production. The scaffold (ECM) was stained with collagen type-I antibody and the thickness was measured under a confocal microscope. Results showed that the thickest scaffold (28.06 ± 0.59 μm) was achieved with 3 × 10⁴ cells/cm² seeding density, 100 μg/mL ascorbic acid concentration under hypoxic and dynamic culture condition. The biocompatibility assessment showed that UCs and SMCs seeded on the scaffold could proliferate and maintain the expression of their markers (CK7, CK20, UPIa, and UPII) and (α-SMA, MHC and Smootheline), respectively, after 14 days of in vitro culture. ECM gene expression analysis showed that the ASC and dermal fibroblast-based scaffolds (control) were comparable. The ASC-based scaffold can be handled and removed from the plate. This suggests that multiple layers of scaffold can be stacked to form the urothelium (seeded with UCs), submucosal layer (ASCs only), and smooth muscle layer (seeded with SMCs) and has the potential to be developed into a fully functional human urethra for urethral reconstructive surgeries.

Update on the Medical and Surgical Management of Urethral Condyloma

INTRODUCTION

Condyloma acuminata (CA) of the urethra presents a management challenge due to high recurrence rates, difficulty in accessing urethral lesions, risk of stricture formation, and potential for sexual dysfunction. While standard treatment modalities are acceptable for some external genital condyloma, they are not always feasible or appropriate for urethral lesions.

OBJECTIVES

We sought to review the literature on epidemiology, presentation, diagnosis and treatment of urothelial CA with a focus on surgical treatment options.

METHODS

We performed a comprehensive literature search of PubMed to identify all studies pertaining to urethral CA through November 2020.

RESULTS

Urethral CA is a relatively rare, but challenging disease to manage with a considerable amount of treatment side effects and downstream morbidity associated. In our comprehensive review we have found a wide selection of treatment modalities ranging from minimally invasive strategies to surgical reconstructive techniques. Proper follow-up to monitor for disease recurrence at the 3-4 month mark is appropriate and will determine subsequent treatment strategies as needed. Future studies and treatment directions include novel drug delivery models to optimize minimally invasive topical drug efficacy.

CONCLUSION

Treatment of urethral CA should be approached in a step-wise fashion. Medical therapy would be an appropriate option for asymptomatic or minimally symptomatic patients with small lesions who desire to avoid any interventions. If patient is symptomatic, has extensive disease burden or has failed medical therapy intervention should be considered with options including PDT, laser ablation or surgical excision with or without urethral reconstruction. Appropriate selection depends on patient characteristics and preferences along with prior treatment history. Kim CJ, Campbell SP, Allkanjari A, et al. Update on the Medical and Surgical Management of Urethral Condyloma. Sex Med Rev 2021;xxx:xxx-xxx.

Transurethral resection of the prostate stricture management

For more than nine decades, transurethral resection of the prostate remains the gold standard for the surgical treatment of lower urinary tract symptoms due to benign prostatic obstruction. The occurrence of urethral strictures after transurethral resection of the prostate is one of the major late complications and has been reported as the leading cause of iatrogenic urethral strictures in patients older than 45 years who underwent urethroplasty. Although several postulations have been proposed to explain the urethral stricture after transurethral resection of the prostate, the exact etiology of urethral stricture after TURP is still controversial. Suggested etiological factors of urethral stricture formation after transurethral resection of the prostate include infection, mechanical trauma, prolonged indwelling catheter time, use of local anesthesia, and electrical injury by a stray current. One single treatment option is not appropriate for all stricture types. The management of urethral stricture following transurethral resection of the prostate includes minimally invasive endoscopic methods, including urethral dilation and direct visual incision, or open surgical procedures with varying urethroplasty techniques. Although scientific studies focusing on urethral strictures after transurethral resection of the prostate are relatively limited and sparse, we can apply the principles of urethral stricture management before making decisions on individual stricture treatment.

Erectile and Ejaculatory Dysfunction After Urethroplasty

PURPOSE OF THE REVIEW

The goal of this paper was to evaluate the impact on erectile and ejaculatory function after anterior and posterior urethroplasty.

RECENT FINDINGS

With a rise in the use of urethroplasty, its impact on sexual function has come into question. For anterior urethroplasties, some degree of erectile dysfunction is common, but this tends to be transient, with most patients having a resolution of any de novo dysfunction by 12 months. Patients with posterior urethral strictures have a very high rate of erectile dysfunction prior to surgery and may show improvement after urethroplasty. Ejaculatory function tends to improve in patients due to alleviation of obstruction while some patients notice degradation in force of ejaculation. While urethroplasty has a minimal permanent effect on sexual function for most patients, there are some patients who notice improvement and others worsening. Patients should be counseled on these risks prior to urethroplasty.

Ventral onlay buccal mucosa graft urethroplasty for female urethral stricture

OBJECTIVES

Female urethral stricture is a rare disease. Urethroplasty with different techniques using grafts or flaps are successful treatment options. The objective of this study was to present our experience with ventral onlay buccal mucosa graft urethroplasty for the treatment of female urethral stricture disease.

METHODS

Eight female patients treated with ventral onlay buccal mucosa graft urethroplasty were identified retrospectively. Patient evaluation included physical examination, uroflowmetry with postvoid residual urine measurement, videourodynamics and urethrocystoscopy. Stricture was identified by videourethrography and/or urethrocystoscopy. Urodynamic evidence of stricture was considered as a persistent low maximum flow rate of <12 mL/s combined with detrusor pressure at maximum measured flow rate of >20 cmH₂ O in the pressure flow study.

RESULTS

The mean age was 50.5 ± 4.14 years. Stricture etiology was idiopathic (62.5%) or iatrogenic (37.5%). Two patients (25%) had undergone prior urethral dilations before buccal mucosa graft urethroplasty. Mean stricture length was 1.62 ± 0.44 cm. Stricture location was as follows: four distal urethra (50%), two mid-distal (25%) and two mid-urethra (25%). The mean postoperative follow-up period was 16.37 ± 5.75 months, and the during follow-up success rate was 100%. No complication, such as incontinence or vaginal fistula, was noted, except dyspareunia developed in one patient (12.5%).

CONCLUSIONS

Ventral onlay buccal mucosa graft urethroplasty is a safe and effective treatment option for female urethral stricture. Unnecessary dilation should not be carried out and buccal mucosa graft urethroplasty in expert centers should be recommended to these patients.

Minimally Invasive Buccal Mucosa Dorsal Graft for Female Distal Urethroplasty

Background

Female urethral stricture (FUS) represents a sporadic condition. There is a lack of data and standardized guidelines on diagnostics and therapeutics. Several surgical techniques have been described for FUS urethroplasty, among which the flap-based or graft-based ones are most reported. Buccal mucosa graft (BMG) represents the gold standard for male urethroplasty, and this can theoretically be applied also to FUS treatment.

Objective

To describe and present preliminary results of a novel minimally invasive technique for buccal mucosa dorsal graft (mini-dorsal BMG) urethroplasty for the treatment of FUS.

Design, setting, and participants

This is a retrospective study on buccal mucosa dorsal graft urethroplasty for the treatment of FUS.

Surgical procedure

Every patient was placed in lithotomic position. Two stiches were placed at 10 and 2 o’clock positions to facilitate the dorsal median urethrotomy. The margins of the incised dorsal urethra at the 12 o’clock position are then dissected from the periurethral tissue. This dissection results in an elliptical raw area between the edges of the urethra over the periurethral tissue. The harvested BMG was fixed with several quilting sutures, using 5-0 and 4-0 absorbable sutures, to cover the raw area. The margins of the graft were sutured to the edges of the incised urethra.

Measurements

A chart review was performed.

Results and limitations

Thirteen patients underwent the mini-dorsal-BMG technique. The median preoperative uroflow was 5.6 (3–13) ml/s, and the median postoperative value was 23.4 (14–58) ml/s.

Conclusions

The mini-dorsal-BMG technique for the treatment of FUS gives good results with low complication rates. Other series and long-term follow-up are necessary to confirm the reproducibility of this technique.

Patient summary

We present the technical aspects and the promising preliminary results of a novel surgical technique for the treatment of female urethral stricture by using the buccal mucosa to correct this invalidating disease.

Open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: the OPEN RCT

BACKGROUND

Men who suffer recurrence of bulbar urethral stricture have to decide between endoscopic urethrotomy and open urethroplasty to manage their urinary symptoms. Evidence of relative clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To assess benefit, harms and cost-effectiveness of open urethroplasty compared with endoscopic urethrotomy as treatment for recurrent urethral stricture in men.

DESIGN

Parallel-group, open-label, patient-randomised trial of allocated intervention with 6-monthly follow-ups over 24 months. Target sample size was 210 participants providing outcome data. Participants, clinicians and local research staff could not be blinded to allocation. Central trial staff were blinded when needed.

SETTING

UK NHS with recruitment from 38 hospital sites.

PARTICIPANTS

A total of 222 men requiring operative treatment for recurrence of bulbar urethral stricture who had received at least one previous intervention for stricture.

INTERVENTIONS

A centralised randomisation system using random blocks allocated participants 1 : 1 to open urethroplasty (experimental group) or endoscopic urethrotomy (control group).

MAIN OUTCOME MEASURES

The primary clinical outcome was control of urinary symptoms. Cost-effectiveness was assessed by cost per quality-adjusted life-year (QALY) gained over 24 months. The main secondary outcome was the need for reintervention for stricture recurrence.

RESULTS

The mean difference in the area under the curve of repeated measurement of voiding symptoms scored from 0 (no symptoms) to 24 (severe symptoms) between the two groups was -0.36 [95% confidence interval (CI) -1.78 to 1.02; p = 0.6]. Mean voiding symptom scores improved between baseline and 24 months after randomisation from 13.4 [standard deviation (SD) 4.5] to 6 (SD 5.5) for urethroplasty group and from 13.2 (SD 4.7) to 6.4 (SD 5.3) for urethrotomy. Reintervention was less frequent and occurred earlier in the urethroplasty group (hazard ratio 0.52, 95% CI 0.31 to 0.89; p = 0.02). There were two postoperative complications requiring reinterventions in the group that received urethroplasty and five, including one death from pulmonary embolism, in the group that received urethrotomy. Over 24 months, urethroplasty cost on average more than urethrotomy (cost difference £2148, 95% CI £689 to £3606) and resulted in a similar number of QALYs (QALY difference -0.01, 95% CI -0.17 to 0.14). Therefore, based on current evidence, urethrotomy is considered to be cost-effective.

LIMITATIONS

We were able to include only 69 (63%) of the 109 men allocated to urethroplasty and 90 (80%) of the 113 men allocated to urethrotomy in the primary complete-case intention-to-treat analysis.

CONCLUSIONS

The similar magnitude of symptom improvement seen for the two procedures over 24 months of follow-up shows that both provide effective symptom control. The lower likelihood of further intervention favours urethroplasty, but this had a higher cost over the 24 months of follow-up and was unlikely to be considered cost-effective.

FUTURE WORK

Formulate methods to incorporate short-term disutility data into cost-effectiveness analysis. Survey pathways of care for men with urethral stricture, including the use of enhanced recovery after urethroplasty. Establish a pragmatic follow-up schedule to allow national audit of outcomes following urethral surgery with linkage to NHS Hospital Episode Statistics.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98009168.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 61. See the NIHR Journals Library website for further project information.

Patient-reported outcomes after buccal mucosal graft urethroplasty for bulbar urethral strictures: results of a prospective single-centre cohort study

OBJECTIVES

To describe patient-reported outcome measures (PROMs) after buccal mucosa graft (BMG) urethroplasty.

MATERIALS AND METHODS

We prospectively collected PROMs in patients who underwent BMG urethroplasty for bulbar urethral strictures between October 2009 and February 2017. Preoperatively and at the first, second and third postoperative follow-up visits, patients completed five PROM questionnaires: the International Prostate Symptom Score (IPSS); the IPSS Quality of Life questionnaire; the Urogenital Distress Inventory Short-Form questionnaire (UDI-6); the International Index of Erectile Function (IIEF)-5 questionnaire, combined with IIEF-Q9 and IIEF-Q10 for assessing ejaculatory and orgasmic functions; and the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTS-QOL) questionnaire. In addition to using these questionnaires, we evaluated maximum urinary flow rate (Q_max ), post-void residual urine volume and total voided urine volume at each follow-up visit. Buccal pain and discomfort were assessed using a visual analogue scale (VAS). Comparison of questionnaire scores was performed using a paired Wilcoxon rank-sum test. Treatment failure was defined as any need for urinary diversion or urethral instrumentation after surgery.

RESULTS

A total of 97 patients met the inclusion criteria. The first postoperative follow-up visit was at a median of 2.1 months (n = 97/97), and the second and third visits were after a median of 7.8 (n = 82/97) and 17.0 months (n = 70/97), respectively. Significant improvements compared to baseline were observed in IPSS, and IPSS-QOL, UDI-6 and ICIQ-LUTS-QOL scores at the first follow-up, and remained improved during the follow-up period (P ≤ 0.001). Patients with mild to no baseline erectile dysfunction experienced a significant decline in erectile function at the first follow-up (median [interquartile range {IQR}] preoperative IIEF-5 score 23.0 [21.0-25.0] vs median [IQR] IIEF-5 score at first follow-up 19.5 [16.0-23.8]; P ≤ 0.001). This decline fully recovered during further follow-up (median [IQR] IIEF-5 score at third follow-up 24.0 [20.5-25.0]; P = 0.86). No significant changes in median orgasmic and ejaculatory function were noted. The first postoperative median (IQR) VAS score was 3.0 (2.0-4.45), and a significant improvement in local pain and discomfort was observed during the follow-up (median [IQR] VAS at third follow-up: 0.0 [0.0-1.0]; P ≤ 0.001). Nine patients (9/97; 9.3%) had treatment failure. Stratifying recurrence based on a difference of <10 mL/s vs ≥10 mL/s between preoperative and postoperative Q_max could not demonstrate a significant difference (P = 0.06).

CONCLUSION

Significant improvements in voiding symptoms and quality of life after surgery were reported. Patients with good baseline erections recovered erectile function during follow-up, although a significant decrease in erectile function was observed at the first follow-up. This study highlights the importance of PROMs in urethral reconstructive surgery, emphasizing that success should not be defined only by stricture-free survival.

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.

Comparison between dorsal onlay and one-sided dorsolateral onlay buccal mucosal graft urethroplasty in long anterior urethral strictures

OBJECTIVE

To compare dorsal onlay (conventional Barbagli) and one-sided dorsolateral onlay (Kulkarni technique) buccal mucosa substitution urethroplasty techniques for the treatment of long anterior urethral strictures.

METHODS

Demographic data, treatment outcomes and success rates of patients who underwent either conventional Barbagli or Kulkarni urethroplasty for the treatment of an anterior urethral stricture longer than 8 cm between January 2010 and March 2019 in our center were retrospectively reviewed.

RESULTS

Demographic parameters of patients who underwent the conventional Barbagli (n = 37) or Kulkarni procedure (n = 31) did not differ. The mean surgical duration and hospital stay were shorter for patients treated with the Kulkarni technique (179.5 ± 30.0 and 3.5 ± 1.2 vs 195.5 ± 28.9 min and 4.4 ± 1.8 days; P = 0.037, P = 0.002). Mean intraoperative blood loss and perioperative complication rates were signficantly lower in patients who underwent the Kulkarni technique than those who underwent the conventional Barbagli technique (164.3 ± 62.9 vs 202.4 ± 78.1 mL; P = 0.033 and 16.1% vs 37.8%; P = 0.046). The mean follow-up time period was 59.8 ± 24.7 and 63.5 ± 26.8 months for Kulkarni and conventional Barbagli techniques, respectively. Success rates based these follow-up time periods were 27 (87.1%) and 26 (70.3%) for the Kulkarni and conventional Barbagli techniques, respectively.

CONCLUSION

The Kulkarni technique should be more preferred for the treatment of long anterior urethral strictures over the conventional Barbagli technique based on surgical outcomes and success rates.

Anterior urethral strictures and retrograde urethrography: An update for radiologists

Urethral strictures are a relatively common affliction of men with the anterior urethra being most frequently affected. Anterior urethral strictures (AUS) typically present with obstructive voiding symptoms and appropriate management is often based on findings at cystourethroscopy and retrograde urethrography (RUG). In particular, determining the number, length, severity and location of urethral strictures is of pivotal importance. The accurate reporting of findings at RUG is dependent on a thorough knowledge of the urethral anatomy as well as recognizing periurethral structures that may opacify during the procedure. Obtaining a diagnostic, high-quality RUG study requires adherence to proper fluoroscopic technique as well as recognizing when to adjust or modify the technique to address pitfalls that may be encountered during the procedure. AUS may be treated by a variety of procedures including urinary diversion, transurethral procedures such as urethral dilation and internal urethrotomy and open surgical repair techniques termed urethroplasty. Some authors have recommended urethroplasty as first-line treatment given the high rate of stricture recurrence with other treatment options. Buccal mucosal grafts are a mainstay of modern urethroplasty. Familiarity with the commonly performed urethroplasty procedures allows radiologists to accurately assess the post-operative urethra thus guiding the management of these patients.

Two-staged anterior urethroplasty using skin flap outside the scrotum: A case report

A thirty-eight-year-old man presented with acute urinary retention due to a long complicated strictures between the meatus and the bulbar urethra. During the first surgery, in addition to the penile skin flap, the flap of the incised skin at 10mm outside the scrotum strip-like tissue was moved medially and sutured onto the incised urethra. After 12 months of the first surgery, we performed the urethroplasty from the bulbar urethra to the meatus. Postoperatively, the patient voided without complications. Thus, this technique using a skin flap outside the scrotum is effective in long complicated urethral strictures.

Multimodality imaging of the male urethra: trauma, infection, neoplasm, and common surgical repairs

OBJECTIVE

The aim of this article is to describe the indications and proper technique for RUG and MRI, their respective image findings in various disease states, and the common surgical techniques and imaging strategies employed for stricture correction.

RESULTS

Because of its length and passage through numerous anatomic structures, the adult male urethra can undergo a wide array of acquired maladies, including traumatic injury, infection, and neoplasm. For the urologist, imaging plays a crucial role in the diagnosis of these conditions, as well as complications such as stricture and fistula formation. While retrograde urethrography (RUG) and voiding cystourethrography (VCUG) have traditionally been the cornerstone of urethral imaging, MRI has become a useful adjunct particularly for the staging of suspected urethral neoplasm, visualization of complex posterior urethral fistulas, and problem solving for indeterminate findings at RUG.

CONCLUSIONS

Familiarity with common urethral pathology, as well as its appearance on conventional urethrography and MRI, is crucial for the radiologist in order to guide the treating urologist in patient management.

Critical analysis of urethroplasty for male anterior urethral stricture: a single-center experience

PURPOSE

Urethroplasty is the most effective treatment method for anterior urethral strictures, which constitute an important health concern for males. This study aims to investigate factors that may predict treatment failure following urethroplasty for anterior urethral strictures and evaluate outcomes of different urethroplasty techniques.

METHODS

This retrospective study utilized univariate and multivariate analyses to identify factors affecting treatment success following different urethroplasty techniques performed by a single surgeon on male patients with anterior urethral strictures. Surgical outcomes of different urethroplasty techniques were evaluated individually.

RESULTS

Urethroplasty procedures performed on 244 patients with a mean age of 54 years and a mean stricture length of 4.7 cm produced a success rate of 79.1%. Multivariate analyses identified stricture length and number of previous internal urethrotomy procedures as factors predicting urethroplasty success (HR 1.265, 95% CI 1.129-1.416, p < 0.001 and HR 1.188, 95% CI 1.038-1.361, p = 0.013, respectively). The eight surgical techniques used by the surgeon produced success rates that varied between 50% and 86.2%.

CONCLUSION

Urethroplasty can offer satisfactory outcomes for anterior urethral strictures. Accordingly, a longer stricture length and greater number of previous internal urethrotomy procedures were associated with greater risk for urethroplasty failure. Moreover, urethroplasty techniques must be selected based on multifactorial evaluation and performed at experienced centers.

[Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap]

OBJECTIVE

To evaluate the clinical effect of single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap.

METHODS

We retrospectively reviewed the clinical database of 22 male patients with penile urethral stricture who received single-stage repair using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap from November 2015 to October 2018. All the cases had no complications, such as skin fistula. The causes of stricture included iatrogenic (14/22, 63.6%), inflammation (2/22, 9.1%) and idiopathic (6/22, 27.3%). A ventral urethrotomy was made in the segment of stricture and extended proximally and distally until the normal calibre urethra was encountered. The oral mucosa graft was secured to the corpus spongiosum in dorsal onlay fashion or underlying corpora cavernosum after resection of the severe scarred urethra. Then the prepared Orandi fasciocutaneous penile skin flap was secured to edges of corpus spongiosum or oral mucosa graft. A 16 F or 14 F Foley catheter was left in situ for a minimum of 3 weeks, at which time a urethrogram was performed to look for extravasation, and the urethroscopy was performed if necessary. Success was defined as an open urethra with Qmax≥15 mL/s and no need for further surgical intervention.

RESULTS

all the 22 patients with a mean age of 52.6 (18-73) years underwent the combined tissue-transfer technique. The mean length of the penile urethral stricture was 5.3 (2.5-10.0) cm and the mean preoperative Qmax was 6.7 mL/s. the mean length of oral mucosa grafts and fasciocutaneous skin flaps were 5.5 (3.2-10.5) cm and 6.0 (3.5-11.0) cm, respectively. The mean operation time was 225 (150-420) minutes and the mean evaluated blood loss was 53 (20.0-110.0) mL. The grafts included buccal mucosa (19/22, 86.4%) and lingual mucosa (3/22, 13.6%). The mean postoperative Q max was 21.2 (15-32) mL/s. A case of skin fistula and 2 cases of recurrent stricture were found, so the technique success rate was 81.8% (18/22) at a mean follow-up of 20.5 (5-51) months. The perioperative complications included 2 cases of infection and skin necrosis, which healed well after conservative treatment.

CONCLUSION

Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap appears to be an excellent option to repair penile urethral stricture with unsalvageable urethral plate and the penile skin is available. The present clinical series showed a successful rate of 81.8% (18/22).

Penile-preserving surgery for male distal urethral carcinoma followed by buccal mucosa urethroplasty

Introduction

We report a case of distal urethral carcinoma treated with segmental urethral excision and reconstruction by staged buccal mucosa urethroplasty.

Case presentation

A 60‐year‐old man presented with difficulty urinating and a palpable mass on the ventral side of his penis. He was diagnosed as having localized distal urethral carcinoma (cT2N0M0) and underwent penile‐preserving surgery with staged urethroplasty using buccal mucosa as substitute tissue. The pathological diagnosis was squamous cell carcinoma of the urethra (T2) with negative surgical margin. At 2 years of follow‐up, there was no recurrence or metastasis, he could void in a standing position with an acceptable urinary stream, and he found the appearance of his external genitalia acceptable.

Conclusion

In cases of distal primary urethral carcinoma, urethroplasty using buccal mucosa graft could be alternative treatment option providing a better postoperative quality of life.

Combined Dorsal Plus Ventral Double Tunica Vaginalis Graft Urethroplasty: An Experimental Study in Rabbits

OBJECTIVE

To investigate the efficacy of a combined dorsal plus ventral double tunica vaginalis graft for urethral reconstruction in a rabbit model through radiology and histopathology.

METHODS

Thirty adult male New Zealand rabbits were randomly divided into 6 groups as follows (n = 5): normal, stricture, and experimental groups A, B, C, and D. In the stricture and experimental groups, the ventral urethra was incised longitudinally, and the dorsal and ventral urethral mucosa were partially removed. Then, 3 × 20 mm and 5 × 20 mm tunica vaginalis grafts were obtained to repair the dorsal and ventral urethral mucosa defects, respectively, and the spongiosum was closed in the experimental groups. The urethral defects were not repaired in the stricture group. The rabbits in experimental groups A, B, C, and D were sacrificed at 2 weeks, 4 weeks, 12 weeks, and 24 weeks postoperatively, respectively, and the rabbits in the stricture group were sacrificed at 4 weeks postoperatively. The urethra was harvested for histological analysis. Urethrography was performed before sacrifice in the stricture group and experimental groups B and D.

RESULTS

The retrograde urethrogram showed that all rabbits in experimental groups B and D had a patent urethra. Histological examination showed that the tunica vaginalis graft completely integrated into the urethra at 4 weeks postoperatively and transformed into a urinary pseudostratified epithelium at 12 weeks postoperatively.

CONCLUSION

Combined dorsal plus ventral double tunica vaginalis graft urethroplasty is a feasible technique for urethral reconstruction in a rabbit model.

Excision and Primary Anastomosis Reconstruction for Traumatic Strictures of the Pendulous Urethra

OBJECTIVES

To present a multi-institutional experience with functional and patient-reported outcomes among men undergoing excision and primary anastomosis (EPA) urethroplasty for pendulous urethral strictures.

METHODS

We describe the technique and present our experience with EPA for focal penile strictures. Patients undergoing urethroplasty (2004-2017) at 2 tertiary referral centers were reviewed, of whom 14 (0.7%) underwent EPA of radiographically confirmed pendulous urethral strictures. Validated questionnaires were utilized to evaluate overall improvement (Patient Global Impression of Improvement), urinary bother (International Prostate Symptom Score), and sexual function (International Index of Erectile Function-5). Treatment success was defined as urethral patency without need for subsequent reconstruction.

RESULTS

Among 14 men undergoing penile EPA, 13/14 (93%) had durable treatment success over a median follow-up of 43 months. No patient reported penile curvature postoperatively. Stricture etiology in most cases was posttraumatic (12/14), of which 4 had a history of urethral disruption secondary to penile fracture and 8 iatrogenic trauma. Median age was 51 years (IQR 30-60) and stricture length 1.0 cm (IQR 1.0-1.4). Erectile function was normal in 8/14 patients preoperatively, and postoperative median International Index of Erectile Function was 21. Most men reported significant global improvement in condition (median Patient Global Impression of Improvement 2, IQR 1-3) and most had only mild urinary bother (median International Prostate Symptom Score 4, quality of life 1). The single treatment failure had a history of hypospadias with multiple prior urethral procedures.

CONCLUSION

For men with short strictures of the pendulous urethra, EPA has a high success rate, without adverse sequelae such as erectile function or penile curvature.