Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction

OBJECTIVES: We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG). METHODS: From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation. RESULTS: Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy. CONCLUSIONS: Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.     

Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures

PURPOSE: We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures. MATERIALS AND METHODS: Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra. RESULTS: At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group. CONCLUSIONS: Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.     

One‐sided anterior urethroplasty: a new dorsal onlay graft technique

OBJECTIVE

To investigate the feasibility, tolerability, safety and efficacy of using a new surgical technique for the repair of anterior urethral strictures to preserve vascular supply to the urethra and its entire muscular and neurogenic support.

PATIENTS AND METHODS

In all, 24 patients (mean age 46 years) underwent a new one‐sided anterior dorsal oral mucosal graft urethroplasty while preserving the lateral vascular supply to the urethra, the central tendon of the perineum, the bulbospongiosum muscle and its perineal innervation. The cause of stricture was instrumentation in three cases (12%), unknown in five (21%), infection in four (17%), and lichen sclerosus in 12 (50%). The stricture site was bulbar in 12 cases (50%) and panurethral in 12 (50%). The mean stricture length was 4.2 cm in patients with bulbar strictures and 10 cm in patients with panurethral strictures. Of 24 patients, 20 patients (83%) had received previous treatments. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation.

RESULTS

The overall mean (range) follow‐up was 22 (12–55) months. Of the 24 patients, 22 (92%) had a successful outcome and two (8%) were failures. One failure was treated using definitive perineal urethrostomy and another failure underwent successful internal urethrotomy.

CONCLUSIONS

The preservation of the one‐sided vascular supply to the urethra and its entire muscular and neurogenic support should represent a slight but significant step toward perfecting the surgical technique of urethral reconstruction using a minimally invasive approach.     

Complex urethral disruptions: In pursuit of a successful reconstruction

OBJECTIVES: We analyzed the methods and outcomes of urethroplasty in men with complex urethral disruptions. METHODS: The medical records of 40 men with complex urethral disruptions were analyzed. Surgical methods were individualized according to stricture location, severity and length of the stricture, bladder neck characteristics and presence of complicating factors. Patients were divided into four groups based on the above characteristics. RESULTS: End-to-end urethroplasty performed in six patients with short bulbar strictures (<3 cm) was successful in all. Elaborated perineal repair was performed in 10 patients with intermediate (3-6 cm) strictures with or without complicating factors. Elaborated perineal repair with urethral substitution was performed in nine patients with long segment stricture (>6 cm). Abdominal transpubic repair was successfully applied to patients with rectourethral fistula or lacerated bladder neck. Success rate of anastomotic urethroplasty was 95% while over all success rate was 85%. CONCLUSION: Guidelines for urethral reconstruction of complex urethral disruptions are predicated on stricture length, location, bladder neck characteristics and associated complicating factors. End-to-end urethroplasty with stricture excision is highly reliable for short strictures for which previous operative repair have failed. Elaborated perineal repair is extremely versatile for intermediate and longer strictures with associated complicating factors. Abdominal transpubic urethroplasty is effective for patients with rectourethral fistula or lacerated bladder neck.     

Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture

PURPOSE: We report the early outcome of dorsal full-thickness penile skin grafts in the repair of bulbar urethral stricture. MATERIALS AND METHODS: During 27 months 29 men with a mean age of 43 years (range 10 to 81) underwent dorsal onlay graft urethroplasty. Followup included retrograde urethrogram at 3 weeks, 3 months and 12 to 18 months, and thereafter when needed. Urinary flow was recorded as subjectively reported by the patients. RESULTS: The technique was used only for bulbar urethral strictures. A total of 23 patients (79%) had undergone previous direct vision urethrotomy and/or open surgery. Dorsal onlay graft urethroplasty was used alone in 12 patients (41%), and was performed with partial stricture excision and ventral strip anastomosis in 13 (45%). In another 4 patients (14%) the procedure was combined with an Orandi flap because the stricture extended significantly into the penile urethra. Penile skin grafts were used in 27 patients (93%), whereas buccal mucosa was harvested in 2. Mean graft length was 6 cm. (range 3 to 9), and width ranged between 1.5 and 3 cm. Outcome was favorable in 28 patients (97%) for a median followup of 19 months (range 10 to 37). One patient had symptomatic proximal stricture recurrence and 3 had radiographic evidence of caliber decrease of the repair but with no impact on urinary flow. CONCLUSIONS: Dorsal onlay graft urethroplasty is a versatile procedure which may be combined with stricture excision and ventral strip anastomosis or an Orandi flap. Conceptually the technique offers the advantages of spread fixation of the graft on a fixed well vascularized surface, which may improve graft neovascularization, reduce graft shrinkage and avoid sacculation. Although the early outcome is promising, dorsal onlay graft urethroplasty has yet to stand the test of time.     

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

Male anterior urethral stricture is scarring of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen, decreasing the urinary stream. Its surgical management is a challenging problem, and has changed dramatically in the past several decades. Open surgical repair using grafts or flaps, called substitution urethroplasty, has become the gold standard procedure for anterior urethral strictures that are not amenable to excision and primary anastomosis. Oral mucosa harvested from the inner cheek (buccal mucosa) is an ideal material, and is most commonly used for substitution urethroplasty, and lingual mucosa harvested from the underside of the tongue has recently emerged as an alternative material with equivalent outcome. Onlay augmentation of oral mucosa graft on the ventral side (ventral onlay) or dorsal side (dorsal onlay, Barbagli procedure) has been widely used for bulbar urethral stricture with comparable success rates. In bulbar urethral strictures containing obliterative or nearly obliterative segments, either a two‐sided dorsal plus ventral onlay (Palminteri technique) or a combination of excision and primary anastomosis and onlay augmentation (augmented anastomotic urethroplasty) are the procedures of choice. Most penile urethral strictures can be repaired in a one‐stage procedure either by dorsal inlay with ventral sagittal urethrotomy (Asopa technique) or dorsolateral onlay with one‐sided urethral dissection (Kulkarni technique); however, staged urethroplasty remains the procedure of choice for complex strictures, including strictures associated with genital lichen sclerosus or failed hypospadias. This article presents an overview of substitution urethroplasty using oral mucosa graft, and reviews current topics.     

Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques

OBJECTIVE: To retrospectively compare the outcome of various techniques of substitution urethroplasty. PATIENTS AND METHODS: Between 1989 and 2000, 109 patients (mean age 39.5 years) underwent substitution urethroplasty for recurrent anterior urethral strictures. Between 1989 and 1995 the procedure was by ventral placement of free grafts (bladder mucosa, buccal mucosa, penile skin) or penile skin flaps. From 1995 onwards the flaps and grafts (buccal mucosa) were applied either ventrally or dorsally. Stricture recurrence and the complications associated with each technique were compared. RESULTS: Ventral onlay repairs were associated with a higher incidence of complications than dorsal repairs, e.g. postvoid dribbling (39% vs 23%, P = 0.01), ejaculatory dysfunction (20% vs 5%, P = 0.03) and flap/graft pseudo-diverticulum or out-pouching (26% vs 2.6%, P = 0.01). Superficial penile skin necrosis was significantly more common with the use of penile skin flaps than with free grafts. There was no significant difference in stricture recurrence, erectile dysfunction and residual penile deformity among the various techniques. CONCLUSIONS: Dorsal free graft/flap onlay urethroplasty gives better results than ventrally placed free grafts/flaps. Dorsal onlay buccal mucosal urethroplasty is a versatile procedure and associated with fewer complications than other substitution methods.     

Lingual mucosal graft urethroplasty for anterior urethral reconstruction

OBJECTIVE: Evaluate the use of lingual mucosal graft (LMG) in anterior urethral strictures. METHODS: From January 2001 to December 2006, 29 men (mean age, 48.5 yr) with anterior urethral strictures underwent graft urethroplasty with LMG. The mean length of stricture was 3.6cm. Patients with bulbar, penile, or bulbopenile strictures received one-stage dorsal free graft urethroplasties. In patients with failed hypospadias repair we performed a two-stage urethroplasty. Criteria for successful reconstruction were spontaneous voiding with no postvoid residual urine and no postoperative instrumentation of any kind. Clinical assessment included the donor site morbidity. RESULTS: Mean follow-up was 17.7 mo. One-stage bulbar and penile urethroplasties without meatal involvement had an 81.8-100% success rate. Bulbopenile urethroplasties were successful in 60% of the cases, whereas one-stage urethral reconstructions in patients with meatal involvement were successful in 66.6%. The two cases of two-stage urethral reconstruction with LMG and buccal mucosal graft after failed multiple hypospadias repairs were unsuccessful. The overall early recurrence rate was 20.7%. Patients with the graft harvested from the tongue reported only slight oral discomfort at the donor site and difficulty in talking for 1 or 2 d. CONCLUSIONS: The mucosa of the tongue, which is identical to the mucosa of the rest of the oral cavity, is a safe and effective graft material in the armamentarium for urethral reconstruction with potential minor risks of donor site complications. LMG may be used alone for short strictures (<5cm) or in combination with buccal mucosa when longer grafts are needed.     

Buccal mucosal urethroplasty: a versatile technique for all urethral segments

OBJECTIVE: To present our experience with buccal mucosa urethroplasty for substitution of all segments of the anterior urethra, as the buccal mucosal graft (BMG) has emerged as the tissue of choice for single-stage reconstruction of bulbar urethral strictures, but its use for reconstructing meatal, pendulous and pan-urethral strictures has not been widely reported. PATIENTS AND METHODS: Between January 1998 and October 2003, 92 patients had a BMG substitution urethroplasty at our institution; 75 had a single-stage dorsal onlay BMG urethroplasty (bulbar 41, pendulous 16 and pan-urethral 18; six combined penile skin flap and BMG) and 17 (pendulous five, pan-urethral 10, bulbar two) a two-stage urethroplasty. Recurrence rates, complications and cosmetic outcomes were analysed retrospectively. RESULTS: Over a median (range) follow-up of 34 (8-72) months, 66 (88%) patients with a one-stage reconstruction (14/16 pendulous; 37/41, 90%, bulbar; 15/16 pan-urethral) remained stricture-free. The mean (range) time to recurrence was 9.4 (3-17) months. Of the nine recurrent strictures, six were managed by one-stage optical urethrotomy and three required a repeat urethroplasty. In patients who had a staged procedure, after a mean follow-up of 24.2 (9-56) months, one had complete graft loss, requiring re-grafting, five required stomal revision after stage 1, and only two (12%) developed a recurrent stricture after the two-stage urethroplasty. CONCLUSION: A one-stage dorsal onlay BMG urethroplasty provides excellent results for strictures involving any segment of the anterior urethra. The BMG appears to be the most versatile urethral substitute, as it can be successfully used for both one- and two-stage reconstruction of the entire anterior urethra.     

Small intestinal submucosa (SIS) graft urethroplasty: short-term results

OBJECTIVE: We evaluated the use of small intestinal submucosa (SIS) graft in penile and bulbar urethroplasties. METHODS: From 2003 to 2004, 20 men (mean age, 41 yr) with anterior urethral strictures underwent urethroplasty using SIS (COOK) as an inlay or onlay patch graft. Stricture location was penile in 1 patient, bulbar in 16, and penile-bulbar in 3. Average stricture and graft lengths were 3 and 5.7 cm, respectively. A dorsal inlay graft was performed in 14 cases, ventral onlay graft in 1, and dorsal inlay plus ventral onlay in 5. Clinical outcome was considered successful if no postoperative procedure was needed. RESULTS: Mean follow-up period was 21 mo (range: 13-35 mo). Seventeen cases (85%) were successful and 3 (15%) were failures. No postoperative complications were related to the use of heterologous graft material, such as infection or rejection. Sixteen successes (94%) were bulbar repairs and one a penile-bulbar repair, with stricture and graft average lengths 2.6 and 5.35 cm, respectively. Cystoscopy at 3 mo revealed adequate calibre lumens, but SIS grafted areas were not completely replaced by urothelium. The three failures were penile and penile-bulbar urethral repairs with stricture and graft average lengths of 5.7 and 7.7 cm, respectively. Recurrences showed fibrous tissue involving the grafted area with extension into the penile and bulbar urethra. CONCLUSIONS: In our short-term results, SIS seems to be a versatile material that may have a role in select urethral reconstructions. Longer follow-up and further investigations in select patients are needed before widespread use is advocated.     

Buccal mucosa graft urethroplasty for anterior urethral stricture repair: evaluation of the impact of stricture location and lichen sclerosus on surgical outcome

PURPOSE: We report our experience with buccal mucosa grafts for anterior urethral strictures. We compared outcomes in the pendulous and bulbar urethra as well as the impact of lichen sclerosus on success. MATERIALS AND METHODS: A total of 53 men underwent buccal mucosa graft urethroplasty from 1997 to 2004 for strictures of all etiologies, including lichen sclerosis in 13. Of the patients 46 underwent 1-stage repair and 7 with full-thickness circumferential disease underwent multistage repair. For 1-stage repair strictures were limited to the bulb in 33 cases and they involved the pendulous urethra in 13. A dorsal onlay was used in 24 cases and a ventral onlay was used in 22. For multistage urethroplasty 2 strictures were in the bulbar urethra and 5 were in the pendulous urethra. Success was defined as no postoperative procedures or complications. RESULTS: The success rate of all urethroplasties was 81% (43 of 53 cases) at a mean followup of 52 months. For bulbar vs pendulous urethroplasty the success rate was 86% (30 of 35 cases) vs 72% (13 of 18, p = 0.23). For 1-stage urethroplasty by graft location success was achieved in 20 of 24 cases (83%) for dorsal onlay vs 17 of 22 (77%) for ventral onlay (p = 0.61), in 18 of 21 (86%) for bulbar-dorsal onlay, in 10 of 12 (83%) for bulbar-ventral onlay, in 2 of 3 (66%) for pendulous-dorsal onlay and in 7 of 10 (70%) for pendulous-ventral onlay. For multistage urethroplasty success was achieved in 2 of 2 cases (100%) for bulbar repair vs 4 of 5 (80%) for pendulous repair. In the 13 patients with lichen sclerosus success was achieved in 4 of 8 (50%) with 1-stage repair vs 4 of 5 (80%) with multistage repair (p = 0.28). Complications developed in 10 of 53 cases (19%), including fistula in 1, urinary tract infection in 1 and stricture in 8 that required treatment, including dilation in 3, internal urethrotomy in 4 and perineal urethrostomy in 1. Five of these 8 recurrent strictures (63%) developed in patients with lichen sclerosus, including 4 in urethras in which 1-stage repair was done for lichen sclerosus. There were no donor site complications, postoperative erectile dysfunction or chordee. CONCLUSIONS: A buccal mucosa graft placed dorsally or ventrally remains an excellent graft material in the bulbar and pendulous urethra. When lichen sclerosus is present, careful consideration should be given to complete excision of the diseased urethra with multistage repair vs accepting a higher rate of stricture recurrence with 1-stage repair.     

One-stage repair of long bulbar urethral strictures using augmented Russell dorsal strip anastomosis: outcome of 234 cases

Objectives

Long bulbar urethral strictures (>2 cm) are not amenable to stricture excision and primary anastomosis procedure, which may result in a short urethra and chordee formation. For such strictures many procedures have been advocated including stricturotomy with subsequent graft or flap onlay, augmented anastomosis, and staged procedures, which is a combination of the Russell graft. We present our 10-yr experience with the augmented Russell procedure using a ventral onlay buccal mucosal patch graft for treatment of long bulbar urethral strictures not amenable to excision and primary anastomosis.

Methods

A total of 234 patients diagnosed by urethrograms as having long bulbar urethral strictures (mean, 4.2 cm) were managed by the augmented Russell urethroplasty. The procedure included excision of most of the diseased segment (mean, 2.8 cm) and anastomosis of a dorsal strip leaving an oval ventral defect. Augmentation was done in all patients using a buccal mucosa patch graft (mean, 4.7 cm).

Results

Mean follow-up was 36 mo. Urethrograms were done at 3 wk and 3 and 6 mo postoperatively and if the patients were symptomatic thereafter. Urethrocystoscopy was performed at 12 and 18 mo. A total of 223 patients completed the follow-up protocol; the overall success rate was 93.7% with 14 (6.3%) patients showing stricture recurrence at different intervals postoperatively. Ten patients in the failure group were successfully managed by single visualized internal urethrotomy (VIU), whereas the other four patients were treated by ventral penile pedicled flap. Postoperative dribbling of urine was noticed by 90 patients (40.4%) and temporary perioral numbness in most patients; no major donor site complications were noted in our series.

Conclusion

The augmented Russell technique is beneficial for long bulbar urethral strictures; 93.7% of the patients were stricture free. In the bulbar region, both ventral and dorsal onlays are applicable with nearly equal success rates. The buccal mucosa patch graft offers excellent material for augmentation.     

The use of lingual mucosal graft in adult anterior urethroplasty: surgical steps and short-term outcome

OBJECTIVES: Investigate the tolerability, safety, and efficacy of using the lingual mucosal graft (LMG) for anterior urethroplasty. METHODS: Ten patients (average age, 41 yr) underwent substitution urethroplasty LMG. Harvesting the graft from the tongue was performed by either the oral surgeon or the urologist. In five patients with penile urethral strictures, the grafts were placed on the dorsal urethral surface as a "dorsal inlay." In five patients with bulbar urethral strictures, the grafts were used as a "dorsal inlay" (3 cases) or "ventral onlay" (2 cases). The average follow-up was 5 mo (range: 3-12 mo). RESULTS: Nine cases (90%) were successful and one (10%) was a failure. Three patients who underwent bulbar urethroplasty showed prior failed repair using buccal mucosal grafts harvested from a single cheek (1 case), from both cheeks (1 case), or from the lip (1 case). The length of the lingual grafts was 4-6cm (mean: 4.5cm) with a width of 2.5cm. No patient developed early or late postoperative complications on the harvest site related to the tongue surgery. No difference was observed in patients in whom the graft harvesting was performed by the oral surgeon compared to the patients in whom the procedure was performed by the urologist. CONCLUSIONS: The surgical technique for harvesting a graft from the tongue is simple and safe. The tongue may be the best alternative donor site to the lip when a thin graft is required for urethroplasty or when the cheek harvesting is not possible.     

Dorsal onlay skin graft bulbar urethroplasty: long-term follow-up

OBJECTIVES: To report retrospectively long-term follow-up in a homogeneous group of patients who underwent dorsal onlay skin graft bulbar urethroplasty and to investigate which factors might influence long-term outcome. METHODS: Thirty-eight patients, with an average age of 43 yr, underwent dorsal onlay skin graft (#12 ventral penile skin and #26 preputial mucosa) bulbar urethroplasty from 1994 to 2000. Of 38 patients, 23 (60.5%) had undergone prior endoscopic procedures. Preoperative evaluation included clinical history, physical examination, retrograde and voiding urethrography, and urethral sonography. Three weeks after surgery, voiding cystourethrography was performed. Patients were followed-up with a clinical evaluation and specific diagnostic tests every 4 mo in the first year and every 12 mo thereafter. Clinical outcome was considered a failure when postoperative instrumentation, including dilation, was needed. RESULTS: Average follow-up was 111 mo (range, 80-149). Of 38 cases, 25 (65.8%) were successful and 13 (34.2%) failures. Patients with stricture length > 6 cm and a previous history of urethrotomies or dilatations seemed to have a higher risk of failure, but this observation was only a trend and did not reach levels of statistical significance. CONCLUSIONS: Penile skin used as dorsal onlay graft for bulbar urethral reconstruction in a homogeneous series of patients showed a success rate ranging from 90% at short-term follow-up to 66% after long-term follow-up. There was no evidence for particular risk factors (length of stricture, number of dilatations and urethrotomies) for failure.     

Opciones de tratamiento quirúrgico en la estenosis de uretra bulbar

ObjectiveTo review the outcome of bulbar urethroplasty using two stage surgical techniques.Material and methodsTwenty-two of the 35 patients studied corresponded to end-to-end urethroplasty (ATT) and 13 to dorsal onlay graft (DOG) in preputial skin or oral mucosa variants. Clinical outcome was considered a failure when postoperative surgery was needed or the uroflowmetry was less than 15 ml/s. The following variables were studied: age, previous surgery, number of urethrotomies and stricture length. The curves and log-rank Curves using the log-rank were elaborated for follow-up and comparison, with the Cox regression model for risk factors.ResultsMean follow-up was 40.02 months. Of all the cases. 85.71% were successful. Of these, 86.36% were in the ATT group and 84.61% in the DOG group. There were no significant differences in the comparative LR test based in stricture length, previous surgery between both group and individualized for each management. The Cox regression model showed a risk of failure in the technique for the elderly patients (OR 2.2), it not achieving statistical significance in the remaining variables.ConclusionsThe success rate achieved with the ATT technique is verified a gold standard option in short strictures. The DOG is shown as a valid option in long strictures in bulbar urethral in medium follow-up, using a oral mucosa or preputial onlay graft. More long-term follow-up must be performed with a greater number of patients to better evaluate these results.     

Dorsal or ventral placement of the preputial/penile skin onlay flap for anterior urethral strictures:does it make a difference?

OBJECTIVE: To report our experience in managing complex anterior urethral strictures with a dorsally/dorsolaterally placed penile/preputial vascularized flap, and to discuss the advantages of this procedure over a traditional ventrally placed flap. PATIENTS AND METHODS: Between 1995 and 1999, 40 patients (mean age 40.5 years) with recurrent strictures of the pendulous and/or bulbar urethra were treated with longitudinal penile/circumpenile flap substitution urethroplasty. Nineteen patients underwent dorsal placement of the flap as an onlay (DO), whereas 21 patients had a ventral onlay (VO). Five patients needed inferior pubectomy to facilitate high proximal placement of the flap. RESULTS: Both groups had statistically similar ages, number of previous interventions, stricture site, length and follow-up. After a median follow-up of 27.5 months, the stricture recurred in three (24%) of the VO and two (11%) of the DO groups (P > 0.05). One patient in the VO group required surgical closure of the urethral fistula. Flap pseudo-diverticulum and/or sacculation with postvoid dribble occurred in six patients in the VO and none in the DO group (P = 0.01). CONCLUSIONS: Dorsal placement of the pedicled flap is anatomically and functionally more appropriate than the traditional VO placement. DO preputial/penile flap urethroplasty is a versatile procedure and can be applied even for long anterior urethral strictures, including reconstruction of the meatus and high proximal bulbar strictures.     

Adult anterior urethral strictures: a national practice patterns survey of board certified urologists in the United States

PURPOSE: We determined the methods and patterns of the evaluation of and treatment for adult anterior urethral stricture disease by practicing urologists in the United States. MATERIALS AND METHODS: A nationwide survey of practicing members of the American Urological Association was performed by a mailed questionnaire. A total of 1,262 urologists were randomly selected from all 50 states, of whom 431 (34%) completed the questionnaire. RESULTS: Most urologists (63%) treat 6 to 20 urethral strictures yearly. The most common procedures used by those surveyed for urethral strictures were dilation (92.8%), optical internal urethrotomy (85.6%) and endourethral stent (23.4%). Minimally invasive procedures are used more frequently that any open urethroplasty technique. Furthermore, most urologists (57.8%) do not perform urethroplasty surgery. When used, the most common urethroplasty surgeries performed were end-to-end anastomotic urethroplasty, perineal urethrostomy and ventral skin graft urethroplasty. Few urologists (4.2%) performed buccal mucosa grafts. For a long bulbar urethral stricture or short bulbar urethral stricture refractory to internal urethrotomy 20% to 29% of respondents would refer to another urologist, while 31% to 33% would continue to manage the stricture by minimally invasive means despite predictable failure. Of the urologists 74% believed that the literature supports a reconstructive surgical ladder, in which urethroplasty is only performed after repeat failure of endoscopic methods. CONCLUSIONS: Most urologists in the United States have little experience with urethroplasty surgery. Most urologists erroneously believe that the literature supports a reconstructive surgical ladder for urethral stricture management. Unfamiliarity with the literature and inexperience with urethroplasty surgery have made the use of endoscopic methods inappropriately common.     

Reconstrucción uretral en pacientes previamente tratados con endoprótesis uretral Memokath™

Purpose

To evaluate the role and success rate of urethral reconstruction in patients with urethral stricture previously treated with thermos-expandable Memokath? urethral endoprosthesis.

Technique of Harvesting Buccal Mucosa for Urethral Reconstruction

Purpose

Buccal mucosa has been used increasingly by urologists for urethral substitution in complex hypospadias repair. We have found buccal mucosa to be useful in reconstruction of bulbar urethral strictures, and describe a simple and reliable technique for harvest.

Materials and Methods

In 11 patients with refractory bulbar urethral strictures a nontubularized onlay patch of buccal mucosa was used for urethral reconstruction. All procedures were done with a 2-team approach in which 1 team (usually an oral surgeon and urologist) harvested the graft from the mouth, while the perineal team simultaneously exposed and calibrated the stricture.

Results

The length of buccal mucosa used ranged from 3.5 to 17 cm. (average 6.4). All patients achieved excellent results. No oral complications were noted, even in patients in whom multiple buccal mucosal grafts were obtained.

Conclusions

With the technique reported, buccal mucosa is a reliable, easily obtained tissue for patch graft urethroplasty. Our 2-team approach decreased operative time considerably.