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Hwang EC, de Fazio A, Hamilton K, Bakker C, Pariser JJ, Dahm P. A Systematic Review of Randomized Controlled Trials Comparing Buccal Mucosal Graft Harvest Site Non-Closure versus Closure in Patients Undergoing Urethral Reconstruction. World J Mens Health 2021; 40:116-126. [PMID: 33663028 PMCID: PMC8761239 DOI: 10.5534/wjmh.200175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/11/2020] [Accepted: 12/25/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose To assess the effects of buccal mucosal graft site non-closure versus closure on postoperative oral morbidity for male undergoing augmentation urethroplasty for urethral stricture. Materials and Methods We included randomized controlled trials. Inclusion criteria were male over the age of 18 with urethral stricture disease requiring reconstruction with buccal mucosal graft harvest. Primary outcomes of the review were postoperative oral pain, need for secondary oral procedures and cosmetic defects. Results We included 5 studies with 346 randomized patients with urethral strictures, of whom 260 completed the trials. In terms of primary outcomes, non-closure graft site may reduce oral pain on postoperative day #1 (standard mean difference [SMD] 0.24 lower; 95% confidence interval [CI] 0.61 lower to 0.12 higher; low certainty evidence [CoE]) but we are uncertain how this impacts pain on postoperative days 3 to 6 (SMD 0.35; 95% CI 0.12 to 0.81 higher; very low CoE). We are also very uncertain as to how it affects the need for secondary oral procedures (risk ratio [RR] 0.22; 95% CI 0.01 to 4.28; very low CoE). Non-closure may increase the risk of cosmetic defects (RR 2.40; 95% CI 0.93 to 6.22; low CoE). Conclusions This review describes the trade-off for buccal mucosal graft site non-closure versus closure for various patient-important outcomes; decision-making will likely hinge on the relative value individual patients and surgeons place on them. The supporting evidence was rated as low and very low, thereby signaling substantial underlying uncertainty and the need for better trials.
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Affiliation(s)
- Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School, Hwasun, Korea
| | - Adam de Fazio
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Kallie Hamilton
- Minneapolis VA Health Care System, Specialty Care, Minneapolis, MN, USA
| | - Caitlin Bakker
- Health Sciences Libraries, University of Minnesota, Minneapolis, MN, USA
| | - Joseph J Pariser
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Specialty Care, Minneapolis, MN, USA.
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Barbagli G, Bandini M, Balò S, Sansalone S, Butnaru D, Lazzeri M. Surgical treatment of bulbar urethral strictures: tips and tricks. Int Braz J Urol 2020; 46:511-518. [PMID: 31961622 PMCID: PMC7239284 DOI: 10.1590/s1677-5538.ibju.2020.99.04] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/11/2020] [Indexed: 11/22/2022] Open
Abstract
The surgical treatment of bulbar urethral strictures is still one of the most challenging reconstructive-surgery problems. Bulbar urethral strictures are usually categorized as traumatic and non-traumatic strictures depending on the aetiology. The traumatic strictures are caused by trauma and they determine disruption of the urethra with obliteration of the urethral lumen, ending with fibrotic gaps between the urethral ends. Differently, the non-traumatic urethral strictures are mainly caused by catheterization, instrumentation, and infection, or they can also be idiopathic. They are usually associated with spongiofibrosis of the segment of the urethra that has been involved. Worldwide, two different surgical approaches are currently adopted for bulbar urethral repair: transecting techniques with end-to-end anastomosis and non-transecting techniques followed by grafting. Traumatic obliterated strictures require transection of the urethra allowing complete removal of the fibrotic tissue that involves the urethral ends. Conversely, non-traumatic, non-obliterated urethral strictures require augmentation of the urethral plate using oral mucosa grafts. Nowadays, it is still difficult to choose the correct surgical management for non-obliterated bulbar stricture repair. Indeed, different surgical techniques have been proposed (pedicled flap vs free graft, dorsal vs ventral placement of the graft, non-transecting technique using or non-using free graft, etc.) but none emerged as the best solution since all techniques have showed similar success and complication rates. Consequently, the final choice is still based on surgeon’s preferences and patient’s characteristics. Within the current manuscript, we like to present some of our tips and tricks that we developed along our prolonged surgical experience on the treatment of bulbar urethral strictures. These might be of interest for surgeons that approach this complex surgery. Moreover, our suggestions want to be useful regardless the type of chosen technique being adaptable for different scenario.
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Affiliation(s)
- Guido Barbagli
- International Center for Reconstructive Urethral Surgery, Arezzo, Italy
| | - Marco Bandini
- Unit of Urology, Urological Research Institute (URI), San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Sofia Balò
- International Center for Reconstructive Urethral Surgery, Arezzo, Italy
| | - Salvatore Sansalone
- Department of Experimental Medicine and Surgery, University of Tor Vergata, Rome, Italy
| | - Denis Butnaru
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Massimo Lazzeri
- Department of Urology, Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital (ML), Rozzano, Milan, Italy
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A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9046430. [PMID: 31139658 PMCID: PMC6500724 DOI: 10.1155/2019/9046430] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/31/2019] [Indexed: 12/21/2022]
Abstract
To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.
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Barbagli G, Montorsi F, Balò S, Sansalone S, Loreto C, Butnaru D, Bini V, Lazzeri M. Treatments of 1242 bulbar urethral strictures: multivariable statistical analysis of results. World J Urol 2018; 37:1165-1171. [PMID: 30220045 DOI: 10.1007/s00345-018-2481-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE We investigated the success rate of different surgical techniques for bulbar stricture repair. METHODS Retrospective study of patients with bulbar urethral strictures treated using different techniques. The primary outcome of the study was to evaluate the overall results of treatment (success vs. failure); the secondary outcome was to evaluate the outcome according to any surgical technique. Cysto-urethrography was performed 1 month following surgery. Patients underwent clinical evaluation, uroflowmetry and residual urine measurement every 6 months for 2 years after surgery and later once on year. When patient showed obstructive symptoms, Qmax < 12 ml/s, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as failures. A bivariable and multivariable statistical analysis was performed. RESULTS Overall, 1242 patients were included in the study with mean age 40 years (range 12-84). Median stricture length was 4 cm (range 1-8). The median follow-up was 103 months (range 12-362). Over 1242 patients, 916 (73.8%) were success and 326 (26.2%) failures. Fourteen different surgical techniques showed a success rate ranging from 87.5 to 14.3%. The multivariable analysis showed that stricture length was an independent predictor factors for failure: p < 0.0001 CI 1146-1509. End-end anastomosis and oral mucosa graft urethroplasty are independent predictor factor of success after internal urethrotomy failure. CONCLUSIONS Our results showed that treatment of bulbar urethral stricture is satisfactory on 73.8% of patients, but with a wide range of success rate (from 14.3 to 87.5%) using different techniques. Oral mucosa is greatly superior to the skin as substitute material.
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Affiliation(s)
| | - Francesco Montorsi
- Division of Oncology, Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Sofia Balò
- Centro Chirurgico Toscano, Arezzo, Italy
| | - Salvatore Sansalone
- Department of Experimental Medicine and Surgery, University of Tor Vergata, Rome, Italy
| | - Carla Loreto
- Department of Biomedical and Biotechnological Sciences, Section of Anatomy and Histology, University of Catania, Catania, Italy
| | - Denis Butnaru
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Vittorio Bini
- Department of Internal Medicine and Biostatistic, University of Perugia, Perugia, Italy
| | - Massimo Lazzeri
- Department of Urology, Humanitas Clinical and Researcher Center, Humanitas University, Rozzano, Italy.
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Angulo JC, Kulkarni S, Pankaj J, Nikolavsky D, Suarez P, Belinky J, Virasoro R, DeLong J, Martins FE, Lumen N, Giudice C, Suárez OA, Menéndez N, Capiel L, López-Alvarado D, Ramirez EA, Venkatesan K, Husainat MM, Esquinas C, Arance I, Gómez R, Santucci R. Urethroplasty After Urethral Urolume Stent: An International Multicenter Experience. Urology 2018; 118:213-219. [PMID: 29751026 DOI: 10.1016/j.urology.2018.04.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/22/2018] [Accepted: 04/27/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume urethral stent. MATERIAL AND METHODS This is a retrospective international multicenter study on patients treated with urethral reconstruction after Urolume stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline, and posturethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure. RESULTS Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14 (22.2%), dorsal onlay buccal mucosa graft (BMG) in 9 (14.3%), ventral onlay BMG in 6 (9.5%), dorsolateral onlay BMG in 9 (14.3%), ventral onlay plus dorsal inlay BMG in 3 (4.8%), augmented anastomosis in 5 (7.9%), pedicled flap urethroplasty in 6 (9.5%), 2-stage procedure in 4 (6.4%), and perineal urethrostomy in 7(11.1%). Success rate was 81% at a mean 59.7 ± 63.4 months. Dilatation or internal urethrotomy was performed in 10 (15.9%) and redo-urethroplasty in 5 (7.9%). Total International Prostate Symptom Score, quality of life, urine maximum flow, and postvoid residual significantly improved (P <.0001). Complications occurred in 8 (12.7%), all Clavien-Dindo ≤2. Disease-free survival rate after reconstruction was 88.1%, 79.5%, and 76.7% at 1, 3, and 5 years, respectively. Explant of individual strands followed by onlay BMG is the most common approach and was significantly advantageous over the other techniques (P = .018). CONCLUSION Urethroplasty in patients with Urolume urethral stents is a viable option of reconstruction with a high success rate and very acceptable complication rate. Numerous techniques are viable; however, urethral preservation, tine-by-tine stent extraction, and use of BMG augmentation produced significantly better outcomes.
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Affiliation(s)
- Javier C Angulo
- Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Hospital Universitario de Getafe, Madrid, Spain.
| | | | - Joshi Pankaj
- Kulkarni Center for Reconstructive Urology, Pune, India
| | | | - Pedro Suarez
- Sección Cirugía Reconstructiva Uretral, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Javier Belinky
- Hospital General de Agudos Carlos G. Durand, Buenos Aires, Argentina
| | - Ramón Virasoro
- Eastern Virginia Medical School, Norfolk, VA; Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina
| | | | | | | | - Carlos Giudice
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Oscar A Suárez
- Hospital San José Tecnológico de Monterrey, Universidad de Monterrey, Nuevo León, Mexico
| | | | - Leandro Capiel
- Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina
| | | | | | | | - Maha M Husainat
- Detroit Medical Center, Detroit Receiving Hospital, Detroit, MI
| | - Cristina Esquinas
- Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Hospital Universitario de Getafe, Madrid, Spain
| | - Ignacio Arance
- Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Hospital Universitario de Getafe, Madrid, Spain
| | - Reynaldo Gómez
- Hospital del Trabajador, Universidad Andrés Bello, Santiago de Chile, Chile
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Barbagli G, Akbarov I, Heidenreich A, Zugor V, Olianas R, Aragona M, Romano G, Balsmeyer U, Fahlenkamp D, Rebmann U, Standhaft D, Lazzeri M. Anterior Urethroplasty Using a New Tissue Engineered Oral Mucosa Graft: Surgical Techniques and Outcomes. J Urol 2018; 200:448-456. [PMID: 29601924 DOI: 10.1016/j.juro.2018.02.3102] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE We investigated whether tissue engineered material may be adopted using standard techniques for anterior urethroplasty. MATERIALS AND METHODS We performed a retrospective multicenter study in patients with recurrent strictures, excluding those with failed hypospadias, lichen sclerosus, traumatic and posterior strictures. A 0.5 cm2 oral mucosa biopsy was taken from the patient cheek and sent to the laboratory to manufacture the graft. After 3 weeks the tissue engineered oral mucosal MukoCell® graft was sent to the hospital for urethroplasty. Four techniques were used, including ventral onlay, dorsal onlay, dorsal inlay and a combined technique. Cystourethrography was performed 1 month postoperatively. Patients underwent clinical evaluation, uroflowmetry and post-void residual urine measurement every 6 months. When the patient showed obstructive symptoms, defined as maximum urine flow less than 12 ml per second, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as having treatment failure. RESULTS Of the 38 patients with a median age of 57 years who were included in study the strictures were penile in 3 (7.9%), bulbar in 29 (76.3%) and penobulbar in 6 (15.8%). Median stricture length was 5 cm and median followup was 55 months. Treatment succeeded in 32 of the 38 patients (84.2%) and failed in 15.8%. Success was achieved in 85.7% of ventral onlay, 83.3% of dorsal onlay, 80% of dorsal inlay and 100% of combined technique cases. No local or systemic adverse reactions due to the engineered material were noted. CONCLUSIONS Our findings show that a tissue engineered oral mucosa graft can be implanted using the same techniques suggested for anterior urethroplasty and native oral mucosa, and guaranteeing a similar success rate.
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Affiliation(s)
| | - Ilgar Akbarov
- Clinic and Policlinic for Urology, University of Cologne, Cologne, Germany
| | - Axel Heidenreich
- Clinic and Policlinic for Urology, University of Cologne, Cologne, Germany
| | - Vahudin Zugor
- Clinic and Policlinic for Urology, University of Cologne, Cologne, Germany
| | - Roberto Olianas
- Department of Urology, Klinikum Lueneburg, Lueneburg, Germany
| | | | - Giuseppe Romano
- Urology Unit, Ospedale Santa Maria alla Gruccia, Montevarchi, Italy
| | - Ulf Balsmeyer
- Department of Urology, Zeisigwald Clinics Bethanien, Chemnitz, Germany
| | - Dirk Fahlenkamp
- Department of Urology, Zeisigwald Clinics Bethanien, Chemnitz, Germany
| | - Udo Rebmann
- Department of Urology, Diakonissen Hospital Dessau, Dessau, Germany
| | - Diana Standhaft
- Department of Urology, Diakonissen Hospital Dessau, Dessau, Germany
| | - Massimo Lazzeri
- Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital, Rozzano, Italy.
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Fu Q, Zhang Y, Zhang J, Xie H, Sa YL, Jin S. Substitution urethroplasty for anterior urethral stricture repair: comparison between lingual mucosa graft and pedicled skin flap. Scand J Urol 2017; 51:479-483. [PMID: 28738760 DOI: 10.1080/21681805.2017.1353541] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Qiang Fu
- Department of Urology, Shanghai 6th Hospital Affiliated to Shanghai Jiaotong University, Shanghai, PR China
| | - Yumeng Zhang
- Urology, The Second Hospital of Shandong University, Jinan, Shadong, PR China
| | - Jiong Zhang
- Shanghai 6th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Hong Xie
- Shanghai 6th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Ying-Long Sa
- Urology, Shanghai 6th People’s Hospital, Jinan, Shadong, PR China
| | - Sanbao Jin
- Shanghai 6th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China
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Fossati N, Barbagli G, Larcher A, Dell’Oglio P, Sansalone S, Lughezzani G, Guazzoni G, Montorsi F, Lazzeri M. The Surgical Learning Curve for One-stage Anterior Urethroplasty: A Prospective Single-surgeon Study. Eur Urol 2016; 69:686-690. [DOI: 10.1016/j.eururo.2015.09.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 09/14/2015] [Indexed: 11/25/2022]
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