Surgical Repair of Bulbar Urethral Strictures: Advantages of Ventral, Dorsal, and Lateral Approaches and When to Choose Them

Buccal mucosal graft urethroplasty in five male dogs with penile urethral stricture at the bulbus glandis

OBJECTIVES

To evaluate the feasibility of correcting penile urethral strictures at the bulbus glandis using buccal mucosal graft (BMG) urethroplasty in dogs.

STUDY DESIGN

Prospective clinical trial.

ANIMALS

Five male dogs with urethral strictures located at the bulbus glandis.

METHODS

Urethrotomy was performed throughout the entire length of the urethral stricture including ~0.5 cm healthy urethra proximal and distal. The scarred tissue and unhealthy mucosa of the strictured urethra were completely excised. The graft was harvested from the buccal mucosa and tubularized at the stricture site using a urethral catheter as the skeleton. The catheter was maintained for 14 days after surgery and removed when no urethral leakage was identified on a positive-contrast retrograde urethrogram. The dogs were discharged after spontaneous urination was confirmed. Six months postoperative follow-up was completed for all dogs with repeated positive contrast urethrogram and an owner questionnaire to score urinary function and quality of life.

RESULTS

The five dogs recovered well following surgery and only one dog experienced a minor complication. All dogs were able to urinate normally after catheter removal. No evidence of leakage was identified on a 14 day postoperative retrograde positive contrast urethrogram and clinically at a median follow-up time of 182 days (range, 182-186). All owners scored the urinary function as excellent and ranked their satisfaction very high 6 months after the procedure.

CONCLUSION

Buccal mucosal graft urethroplasty has positive outcomes for dogs with penile urethral strictures.

Revision Phalloplasty: Evaluation, Algorithms, and Techniques for Salvage after Major Complications

BACKGROUND

Phalloplasty is among the most complex and technically demanding reconstructive procedures. As a larger pool of surgeons perform this difficult procedure, more patients will present with major complications. There are few published data on the comprehensive evaluation and management of these patients, particularly those needing correction of multiple ongoing complications, which may require consideration of starting over with a new microsurgical procedure versus salvage of the existing flap.

METHODS

A literature review on complications of phalloplasty was conducted in combination with drawing upon the experience of 2 high-volume phalloplasty teams (Johns Hopkins/Harvard and GU Recon Clinic/Buncke Clinic) in treating patients with severe postsurgical issues. The purpose was to analyze critical factors and develop algorithms for secondary revision.

RESULTS

Common complications of phalloplasty include urethral strictures and fistulas, diverticula, excess bulk, phalloplasty malposition, hypertrophic or keloidal scarring, and partial or total flap loss. In severe cases, local flaps or free flaps may be required for reconstruction. The decision to revise the existing neophallus or start over with a new flap for phalloplasty is particularly critical. Multidisciplinary team collaboration is essential to develop comprehensive plans that will resolve multiple concomitant problems while meeting patient goals for a functional and aesthetic neophallus.

CONCLUSIONS

Preserving the original flap for phalloplasty is ideal when feasible. Additional local or free flaps are sometimes necessary in situations of significant tissue loss. In severe cases, complete redo phalloplasty is required. The algorithms proposed provide a conceptual framework to guide surgeons in analyzing and managing severe complications after phalloplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

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.

Repair of panurethral stricture: Proximal ventral and distal dorsal onlay technique of buccal mucosal graft urethroplasty

Objective

To report the surgical details and results of our technique of buccal mucosal graft (BMG) urethroplasty for panurethral stricture, as many studies have reported repair of panurethral stricture by single-stage BMG urethroplasty by placing buccal mucosa ventrally, dorsally or dorsolaterally.

Patients and methods

This was an observational analysis of 38 patients with panurethral stricture treated by placing two BMGs, one as a ventral onlay in the proximal bulbar urethra and the other as a dorsal onlay in the distal bulbar and penile urethra. Success was defined as asymptomatic state with or without need for a postoperative single intervention such as dilatation or internal urethrotomy.

Results

The 38 patients had a mean age of 44 years, with lichen sclerosus as the predominant cause of stricture. The ultimate success rate was 84.2% at the end of 3 months and 89.5% at the end of 1 year. Recurrent strictures appeared only in the failed cases during the follow-up period of 11 months. None of the patients needed redo urethroplasty during the follow-up period.

Conclusions

A proximal ventral and distal dorsal onlay technique of BMG urethroplasty is an available alternative for repairing panurethral stricture. The technique described is simple and easily reproducible with encouraging results compared to other similar techniques.

Treatment of long anterior urethral stricture associated to lichen sclerosus

INTRODUCTION

Panurethral stricture associated with lichen sclerosus is a therapeutic challenge. We present the analysis of our results using two urethroplasty techniques based on oral mucosa graft.

MATERIAL AND METHOD

Retrospective study in patients with long anterior urethral stricture (>8cm) associated with lichen sclerosus. Patients received urethroplasty with oral mucosa graft technique according Kulkarni (n=25) or two-step Johanson-Bracka urethroplasty (n=15). Demographics, operative time, complications (Clavien-Dindo), hospital stay, days with catheter, EAV postoperative pain, failure rate, need for retreatment and functional data including IPSS, QoL, Qmax, post void residual (PVR) are evaluated.

RESULTS

In all cases there was involvement of glandular and penile urethra, and in 75% of bulbar urethra. A single graft was used in 22.5%, two in 72.5% and three in 5%. Patients treated at a single step were younger (P=.007). Although the length of the stenosis was equivalent in both techniques (P=.96), relapse and complication rates were higher in two-step surgery (P=.05 and P=.03; respectively) and so was operative time (P<.0001) and overall stay (P=.0002). There were no differences in preoperative IPSS, QoL, Qmax or PVR, neither in postoperative values of IPSS or Qmax; but there was a difference in QoL (P=.006) and PVR (P=.03) favouring single-step urethroplasty. VAS pain on postoperative day 1 was also lower in Kulkarni urethroplasty than in the first step of Johanson-Bracka technique (P<.0001).

CONCLUSIONS

In patients with lichen sclerosus and long anterior urethral stricture Kulkarni urethroplasty provides more efficient and better patient reported outcomes than Johanson-Bracka urethroplasty. It also prevents cosmetic, sexual and voiding temporary deterioration inherent to 2-step surgery.

Graft Use in Bulbar Urethroplasty

The gold standard for bulbar urethroplasty has been excision and primary anastomosis. Application of this approach is generally limited to strictures that are 2 cm or less in the bulbar urethra due to penile shortening. Strictures greater than 2 cm are successfully treated with augmentation urethroplasty wherein the narrowed segment is not excised but widened with the use of a skin flap or a tissue graft. Buccal mucosa is the most prevalent tissue for bulbar urethral stricture repair for strictures greater than 2 cm. Outcomes for the different graft locations are similar, approximately 90%.

Approach to bulbar urethral strictures: Which technique and when?

Bulbar urethra is the most common site of anterior urethral stricture and this stricture develops secondary to idiopathic (40%), iatrogenic (35%), inflammatory (10%), and traumatic (15%) causes. Various techniques and approaches with buccal mucosal graft have been described. We wanted to describe different techniques of repair with specific advantages.