Dorsal oral mucosa graft in combination with ventral penile flap as an alternative to repair obliterative stenosis of the anterior urethra in a single surgical time

Preservation of the native urethral plate and corpus spongiosum combined with buccal mucosa graft plus Orandi's penile skin flap as an alternative to staged urethroplasty for narrow penile strictures

OBJECTIVE

In narrow anterior urethral strictures, the combined buccal mucosa graft (BMG) with pedicled penile skin flap (PSF) represents a well-known effective alternative to staged urethroplasty. We hypothesized that if the native urethral plate and adjacent corpus spongiosum were preserved, a narrower flap would be needed, and reinforced ventral stability could be achieved without compromising the surgical outcome.

METHODS

Twelve patients with narrow penile urethral strictures underwent single-stage augmentation urethroplasty using a combined technique. A BMG was quilted to the corpora cavernosa in a dorsal onlay approach, and a longitudinal ventral PSF was transposed ventrally and sutured to the scarred native urethral mucosa on one side and to the BMG on the other side to form a neourethra of triangular form. The preserved corpus spongiosum was wrapped and fixed around the flap ventrally.

RESULTS

The median age was 47 years (IQR 35-59), and the median stricture length was 5 cm (IQR 3, 8-7). The median surgical time was 205 min (IQR 172-236). The overall success rate (SR) was 91.7% without sacculation or diverticula formation after a median follow-up period of 38 months (IQR 33-40). Three transient fistulas healed through prolonged urinary diversion. Five patients (41.7%) reported postvoid dribbling following urethroplasty.

CONCLUSION

Preservation of the native urethral plate is a valuable adjunct to the combination of graft and flap for single-stage augmentation urethroplasty for narrow urethral strictures, with satisfactory mid-term success and an acceptable complication rate.

Single-stage combined urethroplasty for extended strictures of the anterior urethra of tuberculous origin

Background. Urethral strictures are currently one of the most complex pathologies in reconstructive urology. The most promising direction in this area is the development of single-stage surgical interventions that meets modern requirements for the quality of life of patients.The aim of the study. To evaluate the possibility and the effectiveness of surgical treatment of extended recurrent tuberculous urethral strictures in men using a combination of a skin flap and a buccal graft. In the literature, there is no description of the use of this technique in patients with urethral tuberculosis.Materials and methods. We observed 44 patients with urethral tuberculosis. Three men from this group of patients were diagnosed with tuberculous (post-tuberculous) extended recurrent stricture of the anterior urethra and they underwent combined single-stage urethroplasty with a ventral fasciocutaneous flap and a buccal graft using the inlay method in the penile region and with a buccal graft using the ventral onlay method in the bulbous urethra. Ultrasound of the urethra served as a method that determines the possibility of performing this surgery in case of maintaining a sufficient width of the urethral plate with a moderate degree of spongiofibrosis.Results. Patients were under observation for 34, 50 and 54 months and have good long-term functional results – all patients have unassisted urination and no residual urine. Post-micturition dribbling persists in 1 patient. The overall effectiveness of the treatment of these strictures, taking into account the treatment of repeated cases of the disease recurrence, is high.Conclusion. This technique demonstrates the possibility of performing a single-stage reconstruction of the anterior urethra in patients with extended recurrent tuberculous (post-tuberculous) urethral strictures and is also applicable for the surgical treatment of urethral strictures of other origins.

Is colorectal mucosa a reasonable graft alternative to buccal grafts for urethroplasty?: A comparison of graft histology and stretch

OBJECTIVE

To compare the histological properties and stretch of colorectal mucosal grafts (CMG) and buccal mucosal grafts (BMG) and to evaluate the impact of age, medical comorbidity and tobacco use on these metrics.

MATERIALS AND METHODS

Samples of BMGs from patients undergoing augmentation urethroplasty were sent for pathologic review. CMGs were collected from patients undergoing elective colectomy. CMGs were harvested fresh, at full thickness from normal rectum/sigmoid. Patients with inflammatory bowel disease, prior radiation, or chemotherapy were excluded.

RESULTS

Seventy two BMGs and 53 CMGs were reviewed. While BMGs and CMGs were both histologically composed of mucosal (epithelium + lamina propria) and submucosal layers, the mucosal layer in CMG had crypts. The outer epithelial layers differed significantly in mean thickness (BMG 573μm vs. CMG 430μm, p=0.0001). Mean lamina propria thickness and submucosal layer thickness also differed significantly (BMG 135μm vs. CMG 400μm, p<0.0001; BMG 1090μm vs. CMG 808μm, p = 0.007, respectively). Mean delta stretch, as to length and width, was greater for CMG (118% x 72%) compared to BMGs (22% x 8%), both p<0.001.

CONCLUSION

CMGs and BMGs significantly differ histologically in layer composition, width and architecture, as well as graft stretch. Given its elastic properties, CMG may be useful in covering large surface areas, but its thin epithelium, thick lamina propria and additional muscularis mucosal layer could impact graft take and contracture.

Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures

Background

Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra.

Objective

To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction.

Design, setting, and participants

Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study.

Surgical procedure

The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula.

Measurements

Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure.

Results and limitations

We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5–8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5–26 ml/min). The median follow-up was 25 mo (IQR 10–30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique.

Conclusions

In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra.

Patient summary

Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.

Update on the management of penile and meatal strictures

PURPOSE OF REVIEW

Treatment of penile and distal urethral strictures including the fossa navicularis and the meatus remains challenging due to their adverse etiology and lack of ventral tissue support. In this contemporary review, we summarize the available evidence and recent advancements in reconstructive techniques.

RECENT FINDINGS

Over the last years, several refinements of already established techniques have been added to the reconstructive armamentarium in the management of penile urethral strictures. These include the single-stage combination of flap and graft, the additional use of tissue glue, or an optimized single-stage tubularization using a free graft.

SUMMARY

There is a shift toward an increased use of single-stage procedures even in complex strictures of the penile and distal urethra. This is reflected by advancements and refinements in operative techniques. Nonetheless, staged urethroplasty remains a cornerstone of curative management in such patients with durable success rates. Future research should focus on identifying distinct patient and stricture characteristics to determine the individual therapeutic approach with optimal functional outcomes.

A new double graft technique in urethroplasty for complex urethral stenosis: preliminary findings

The management of complex urethral stenosis may involve different surgical techniques. As retraction of the graft may account for surgical failure, this risk increases in patients with more extensive stenosis requiring a graft of greater diameter. Although double grafts have already been used to maximize success in these cases, we propose a modified technique for urethroplasty with longitudinal urethral incision. The hypothesis was that this technique would increase the lumen by using only a urethral incision on the dorsal surface. Two patients presenting with recurrent urethral stenosis underwent urethroplasty using a double graft of oral mucosa that preserves the integrity of the spongy tissue and allows ventral inlay graft fixation using a midline relaxing incision in the portion of the urethra with stenosis. In both cases, the urethrocystoscopy and uroflowmetry performed after surgery showed a pervious and complacent urethra. After four and six months of follow-up, the postoperative outcomes were satisfactory for both patients. Further studies involving larger numbers of patients and long-term follow-up are required to evaluate the effectiveness of this method.