DORSAL ONLAY GRAFT URETHROPLASTY USING PENILE SKIN OR BUCCAL MUCOSA IN ADULT BULBOURETHRAL STRICTURES

Purpose

Preputial skin graft is used routinely for urethral reconstruction in patients with stricture disease. Alternative donor sites include extrapenile skin, bladder mucosa and buccal mucosa. Recently buccal mucosa graft has been suggested when local epithelial tissue is not available. We describe our experience with 37 patients undergoing 1-stage correction of bulbar urethral stricture using a penile skin (31) or buccal mucosa (6) graft.

Materials and Methods

In 37 patients with bulbar urethral strictures a nontubularized dorsal onlay graft was used for urethral reconstruction. A preputial skin graft was used in 31 patients and a buccal mucosa graft in 6 with a paucity of local skin. Buccal mucosa graft length ranged from 2.5 to 5 cm. (average 4) and preputial skin graft was 2.5 to 12 cm. long (average 4.7). A dorsal approach to the urethral lumen was used in all patients who underwent onlay graft urethroplasty.

Results

Mean followup was 21.5 months for all 37 patients, 23 months for 31 treated with preputial skin graft and 13.5 months for 6 treated with buccal mucosa graft. The clinical outcomes were considered a failure anytime postoperative instrumentation was needed, including dilatation. In the series 34 cases (92%) were classified as a success and 3 (8%) as failure.

Conclusions

Onlay graft urethroplasty provided excellent results in 92% of adults with bulbourethral stricture. The dorsal approach to the urethra allowed the use of foreskin or buccal mucosa graft for reconstruction of the adequate urethral lumen.     

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.     

A Buccal Mucosal Harvesting Technique for Urethral Reconstruction

Purpose

A step-by-step harvesting technique for buccal mucosa is described that maximizes graft yield while minimizing potential donor site morbidity in urethral reconstruction.

Materials and Methods

A specialized oral retractor was used to expose and retract the buccal mucosal lining of the oral cavity for graft harvesting in 12 patients.

Results

Adequate buccal mucosal graft size was obtained for each reconstruction. There were no oral donor site or urethral recipient site complications.

Conclusions

This harvesting technique offers a simple and effective method for optimizing buccal mucosal graft harvests.     

Single Stage Reconstruction of Complex Anterior Urethral Strictures: Combined Tissue Transfer Techniques

Purpose

Reconstruction of most urethral strictures is possible with anastomotic, graft or skin flap procedures alone. We describe the combination of tissue transfer techniques to preserve the urethral plate and reconstruct long and complex urethral strictures in 1 stage.

Materials and Methods

We reviewed the results in 25 patients who underwent anterior urethroplasty requiring more than 1 tissue transfer technique to achieve urethral reconstruction in 1 stage.

Results

Outcome was excellent in 22 patients (88%). Seven patients with pan-urethral strictures (mean length 19 cm.) required a fasciocutaneous flap combined with a buccal mucosa, bladder epithelium or skin graft. A total of 13 patients with focally dense strictures underwent excision of the most severe portion of the stricture with dorsal reapproximation, thereby improving the quality of the urethral plate and allowing simultaneous flap or graft onlay reconstruction. Five patients with multiple separate strictures required a distal onlay fasciocutaneous flap with excision and end-to-end anastomosis of a separate, more proximal stricture.

Conclusions

A thorough knowledge of the vascular supply of the urethra allowed creative application of different tissue transfer techniques, enabling 1-stage reconstruction of complex urethral strictures. An excellent outcome was achieved by preserving or revising the urethral plate and avoiding the problems associated with hair-bearing flaps and 2-stage procedures.     

Stricture repair using free graft

Summary Single stage urthroplasty with an onlay patch graft of penile skin or buccal mucosa is an effective treatment for patients with complex anterior urethral stricture disease. Using buccal mucosa, operative time is substantially reduced by using a two-team approach in which one team harvests the graft from the mouth while a perineal team simultaneously exposes and calibrates the stricture. Excellent results can be expected using grafts urethral substitution in men with refractory bulbar strictures. Focal areas of severe stenosis may be excised from the graft bed. For patients with long or dense strictures, grafts may easily be combined with other tissue transfer techniques.      

Single-stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosal grafts

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? This technique has been reported to have an excellent success rate in the bulbar urethra, although no data exists for its use in the penile urethra. This is the first study to report successful use of the technique in the reconstruction of penile urethral strictures.

OBJECTIVE

• ? To review our initial experience with single‐stage overlapping dorsal and ventral buccal mucosa graft (BMG) urethroplasty for the reconstruction of complex anterior urethral strictures.

PATIENTS AND METHODS

• ? Among 696 urethroplasties performed at two tertiary urethroplasty centres from October 2007 to September 2010, single‐stage urethral reconstruction using urethral plate incision and/or excision and overlapping dorsal and ventral BMGs was used in 36 men (5%) with complex urethral strictures (mean length 4.5 cm).
• ? Demographic and perioperative data was tabulated and outcomes were analysed.

RESULTS

• ? Stricture location was bulbar (61%), penile (19%), or both bulbar and penile (20%).
• ? Dorsal grafts, applied only within the most severely strictured segment, measured a mean 42% of the opposing ventral graft length.
• ? At a mean follow‐up of 15.7 months, 32 of the 36 cases were successful (89%).
• ? Repeat urethroplasty was performed in all four recurrences, three of which were successful at a mean follow‐up of 16 months.

CONCLUSION

• ? Single‐stage reconstruction of focally obliterative long urethral strictures using overlapping dorsal and ventral BMGs is safe and effective.

     

Reconstruction of Membranous Urethral Strictures

Purpose of Review

Due to the proximity of the rhabdosphincter and cavernous nerves to the membranous urethra, reconstruction of membranous urethral stricture implies a risk of urinary incontinence and erectile dysfunction. To avoid these complications, endoscopic management of membranous urethral strictures is traditionally favored, and bulboprostatic anastomosis is reserved as the main classical approach for open reconstruction of recalcitrant membranous urethral stricture. The preference for the anastomotic urethroplasty among reconstructive urologists is likely influenced by the familiarity and experience with trauma-related injuries. We review the literature focusing on the anatomy of membranous urethra and on the evolution of treatments for membranous urethral strictures.

Recent Findings

Non-traumatic strictures affecting bulbomembranous urethra are typically sequelae of instrumentation, transurethral resection of the prostate, prostate cancer treatment, and pelvic irradiation. Being a different entity from trauma-related injuries where urethra is not in continuity, a new understanding of membranous urethral anatomy is necessary for the development of novel reconstruction techniques. Although efficacious and durable to achieve urethral patency, classical bulboprostatic anastomosis carries a risk of de-novo incontinence and impotence. Newer and relatively less invasive reconstructive alternatives include bulbar vessel-sparing intra-sphincteric bulboprostatic anastomosis and buccal mucosa graft augmented membranous urethroplasty techniques. The accumulated experience with these techniques is relatively scarce, but several published series present promising results. These approaches are especially indicated in patients with previous transurethral resection of the prostate in which sparing of rhabdosphincter and the cavernous nerves is important in attempt to preserve continence and potency. Additionally, introduction of buccal mucosa onlay grafts could be especially beneficial in radiation-induced strictures to avoid transection of the sphincter in continent patients, and to preserve the blood supply to the urethra for incontinent patients who will require artificial urinary sphincter placement. The evidence regarding erectile functional outcomes is less solid and this item should be furtherly investigated.

     

Management of failed hypospadias: choosing the right method and achieving optimal results

Objective

Because of the complexity of the abnormalities and limited options for reconstruction of failed hypospadias, creating a neourethra presents a challenge to surgeons. We reviewed our experiences with staged urethroplasty strategies to repair the penis of failed hypospadias.

Materials and methods

We retrospectively reviewed 56 consecutives patients following multiple unsuccessful hypospadias repairs from 2010 to 2016. Patients were divided into the following two groups based on their penile conditions and urethroplasty procedures: staged buccal mucosa graft Bracka urethroplasty (group1) and two-stage urethroplasty with additional buccal mucosa graft augmentation of the dorsal urethral plate (group2).

Result

Median follow-ups were 26.5 months (12–59 months) and 28.6 months (14–59 months) in the group 1 and group 2. After the second stage, three patients (11.1%) in group 1 and two patients (6.89%) in group 2 did not have a meatal opening at the top of the glans. Three patients (11.1%) in group 1 and 4 patients (13.79%) in group 2 had urethrocutaneous fistulas. One patient (3.70%) in group 1 and no patients in group 2 had meatal stenosis. Two patients (6.89%) in group 2 and no patients in group 1 had urethral strictures; all patients with strictures were cured using dilations, so follow-up surgeries were not required. No patients in either group had signs of diverticulum or residual chordee. Three patients (11.1%) in group 1 and 4 patients (13.79%) in group 2 needed reoperations.

Conclusion

Failed hypospadias repairs were often due to the underestimation of the penile conditions at the prior surgery. The results indicated that two-staged strategies were preferred for treating complex situations during the intermediate period of our study. Staged buccal mucosa graft Bracka urethroplasty and two-stage urethroplasty with additional buccal mucosa graft augmentation of the dorsal urethral plate severed as reliable approaches in complex hypospadias cases and could improve the overall success rate.

     

What is the Best Technique for Urethroplasty?

Context

There is no clear evidence that determines which type of urethroplasty to perform under which particular circumstance.

Objective

To review the options for urethroplasty at different sites in the urethra and for different types of stricture indicating which procedure should be used in which circumstances according to the best available evidence.

Evidence acquisition

Recent publications have been reviewed and supplemented with the authors’ personal experience.

Evidence synthesis

Currently, in the developed world, the most common types of stricture are relatively short and are situated in the bulbar urethra. There is good evidence that these are best treated by excision and end-to-end anastomosis if they are short enough or by patch urethroplasty using a buccal mucosal graft if they are longer.Distal penile urethral strictures are the next most common type of stricture, but the evidence base is weaker, although there is agreement that penile strictures due to lichen sclerosus often require a staged approach to reconstruction, again using buccal mucosal grafts.Urethroplasty for pelvic fracture urethral injury is an altogether different type of technique for an altogether different type of pathology. There is good evidence that this is best treated by bulbo-prostatic anastomotic urethroplasty.Other types of strictures and salvage surgery have no good evidence base and are specialised areas where experience and judgement are necessary.

Conclusions

The evidence base for urethral surgery has been developed for the more common types of urethral strictures in the last 20 yr, but it is still as much an art as it is a science.     

Results of buccal mucosa grafts for repairing long bulbar urethral strictures

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVES

To report the medium‐term results at our institution of repairing long bulbar urethral strictures with buccal mucosal grafts.

PATIENTS AND METHODS

Between January 2003 and June 2007, a buccal mucosa graft repair was used in 34 patients with recurrent bulbar strictures >2 cm. The follow‐up included uroflowmetry with an ultrasonographic estimate of residual volume at 3 months, 1 year and yearly thereafter, or at the onset of obstructive voiding symptoms. A retrograde urethrogram with a voiding cysto‐urethrogram was taken at 6 months. Flexible urethroscopy was used whenever a recurrent stricture was suspected. A successful outcome was defined as normal voiding with no stricture on the voiding cysto‐urethrogram and no need for subsequent instrumentation.

RESULTS

The median (range) age of the patients was 55.5 (23–74) years. The mean (sd ) preoperative maximum flow rate was 6.6 (2.5) mL/s with a mean (sd ) residual volume of 51.7 (89.7) mL. Seven patients (21%) had had one or more previous urethral dilatations, 15 (44%) had undergone one or more internal urethrotomies and 10 (30%) received both treatments. Eight patients (24%) had previous open urethral surgery; two had no previous treatment. A dorsal onlay technique was used in 30 patients, a ventral onlay in one, a combined technique (dorsal onlay and ventral fasciocutaneous flap) in two and a two‐stage buccal mucosa urethroplasty in one. The mean (sd ) operative duration was 147 (36) min, and the stricture length and buccal mucosa graft length were, respectively, 3.2 (1.2) cm and 4.4 (0.6) cm. Follow‐up was available in 33 patients (97%) with a mean of 23 (15.4) months. The success rate was then 94%. Both failures occurred within the first year and were managed successfully by internal urethrotomy. The mean (sd ) postoperative maximum flow rate was 20 (11) mL/s with a mean (sd ) residual volume of 46 (68) mL. There were no medium‐term donor‐site complications. Postmicturition dribbling was noted in eight patients (24%). None of the patients had de novo impotence or urinary incontinence, and to date no patient has needed a repeat open reconstruction.

CONCLUSION

Our results show that in patients with bulbar urethral strictures of >2 cm, urethroplasty using buccal mucosa is feasible, with very encouraging medium‐term results. We confirm that this type of reconstruction could be considered the standard of care for bulbar strictures of >2 cm.     

Bulbar urethral stricture repair with buccal mucosa graft urethroplasty

OBJECTIVES: Evaluation of the use of buccal mucosa graft as single-stage urethral reconstruction in an adult population with a stenosis of the bulbar urethra. METHODS: In our Department between April 1996 and February 1999, 20 patients with bulbar urethra stenosis underwent single-stage urethroplasty using a buccal mucosa graft. Mean age of patients was 52 years (range 14-70). The etiology of urethral stricture was inflammation (4 cases), iatrogenic (5 cases) and idiopathic (11 cases). A ventral onlay patch (mean length 3.6 cm, range 2.5-5) was employed in all cases. RESULTS: During the follow-up (median 13 months, range 6-28) the overall success rate was 80%. The success rate was 75% for inflammatory strictures, 80% for iatrogenic strictures and 81% for strictures of unknown etiology. CONCLUSIONS: Although longer follow-up is needed, free graft urethroplasty with buccal mucosa graft represents a simple surgical option which has produced encouraging results. This is probably due to the quality of the tissue employed which at present seems to represent the first-choice solution in selected cases.     

Use of Free Grafts in Urethral Stricture Reconstruction

Purpose

The indications, contraindications and results of free graft urethroplasty are determined.

Materials and Methods

A retrospective review was done of 40 consecutive patients who underwent free graft urethroplasty with penile and preputial skin, buccal mucosa and bladder epithelium.

Results

Of the 35 patients in whom adequate followup data were available the outcome was successful in 30 (86 percent). Success was unrelated to donor site, prior intervention or cause of stricture. Failure was attributed to placement of grafts onto the penile urethra and patient age.

Conclusions

For strictures in the bulbar urethra the success rate of free grafts was high. Failures occurred in patients in whom full thickness skin grafts were extended far onto the penile urethra.     

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.     

口腔内黏膜尿道成形治疗前尿道狭窄10年经验总结

目的 探讨口腔内黏膜尿道成形治疗尿道狭窄的长期效果. 方法 2001年1月至2010年12月,应用口腔内黏膜(颊黏膜和舌黏膜)尿道成形治疗前尿道狭窄255例.尿道狭窄段长度3 ～18 cm,平均6 cm.尿道成形采用保留原尿道板的扩大尿道成形术或埋藏黏膜条背侧替代尿道成形术.对49例尿道狭窄段≥8 cm者采取双侧颊黏膜拼接、颊粘膜与舌黏膜拼接或双侧连续长条舌黏膜尿道成形. 结果 术后随访8 ～120个月,平均37个月.230例患者排尿通畅,尿线粗,最大尿流率为16～51 ml/s,平均26 ml/s.尿道造影显示重建段尿道管腔通畅.总成功率90.2％.25例患者于术后1年内发生并发症,其中尿道再次狭窄17例,尿道皮肤瘘8例.17例尿道再狭窄患者中15例再次行口腔内黏膜尿道成形,2例吻合口狭窄行尿道内切开,术后排尿通畅;8例尿道皮肤瘘均接受尿瘘修补术后治愈. 结论 口腔颊黏膜和舌黏膜均是良好的尿道替代物,舌黏膜取材较颊黏膜更为便利;口腔内多种黏膜的组合移植重建尿道是治疗长段前尿道狭窄( ≥8 cm)的有效方法.     

A New Biaxial Epilated Scrotal Flap for Reconstructive Urethral Surgery

Purpose

We describe a new type of perineum based scrotal flap with biaxial vascularization supplied by both superficial perineal arteries. Flap length of up to 20 cm. may be attained for urethral reconstruction.

Materials and Methods

A total of 37 men with complex urethral stenosis of different etiologies underwent surgery using 1 of 3 urethroplasty techniques based on this new flap. The whole anterior urethra, including pendulous and bulbar segments, was reconstructed with a scrotal patch in 10 patients. A scrotal tubular flap was used as a substitute for the bulbar urethra in 7 patients and for the membranous portion in 4. Bulbar urethroplasty with a scrotal island patch was performed in 16 patients.

Results

Of the patients 86% achieved normal voiding after 1-stage urethroplasty. Mean followup was 39.5 months.

Conclusions

The excellent axial vascularization of this new flap permits successful resolution of the most complex urethral stenoses regardless of extension, location and etiology.     

Buccal Mucosal Grafts for Urethroplasty: Comparison of Postoperative Oral and Perineal Morbidity

INTRODUCTION

A prospective study of postoperative oral and perineal pain experienced by a group of patients undergoing buccal mucosal graft harvest for urethral reconstruction.

PATIENTS AND METHODS

A consecutive group of 24 male patients undergoing buccal mucosa graft harvest for urethral recon8truction of stricture disease was prospectively studied between June 2006 and December 2008. All patients were examined pre-operatively and entered into the study prospectively. After surgery, all patients were reviewed at 24 h and 48 h. On both occasions, they were asked to complete a proforma containing visual analogue pain scales for both the oral donor site as well as the perineum.

RESULTS

A statistically significant higher level of pain was experienced from the perineum than the oral donor site on both the first and second postoperative days.

CONCLUSIONS

Comparative analysis of visual analogue pain scale scores between oral donor site and perineum showed that patients experience significantly more pain from the latter postoperatively.     

Management of Urethral Stent Failure for Recurrent Anterior Urethral Strictures

Background

Urethral stent placement for recurrent anterior urethral strictures may cause restenosis and complications.

Objective

To describe our experience with patients who had restenoses and complications following urethral stent placement for the treatment of recurrent anterior urethral strictures.

Design, setting, and participants

We evaluated retrospectively the records of 13 men with anterior urethral stricture who experienced restenosis and complications after stent insertion. We recorded stent position, prestent and poststent urethral procedures, restenosis location, stent-related complications, and management of stent failures.

Surgical procedure

The stent was removed en bloc with the whole strictured urethral segment or wire by wire after a ventral or a double-ventral plus dorsal-sagittal urethrotomy and stent section.

Measurements

Successful outcome was defined as standard voiding, without need of any postoperative procedure, and full recovery from complications.

Results and limitations

Four patients did not undergo surgery and the stent was left in situ. Of these patients, two required permanent suprapubic cystostomy. Nine patients underwent challenging surgical stent removal and salvage urethrostomy: After the first stage, three patients are waiting for further reconstructive steps, five elected the urethrostomy as a permanent diversion, and one completed the staged reconstruction using a buccal mucosa graft at the second stage. After surgery, seven of the nine patients (77.8%) were free of strictures and stent-related complications, while a restenosis occurred in two of the nine (22.2%) cases.

Conclusions

The management of urethral stent failure represents a therapeutic challenge. The stent risks converting a simple stenosis into a complex stenosis requiring a staged urethroplasty, a definitive urethrostomy, or a permanent suprapubic diversion.     

Surgical Management of Fossa Navicularis and Distal Urethral Strictures

Purpose of Review

Urethral reconstruction has evolved in the last several decades with the introduction of various techniques including fasciocutaneous skin flaps and buccal mucosal grafts. However, distal urethral strictures have continued to be a reconstructive challenge due to tendency for adverse cosmetic outcomes, risks of glans dehiscence or fistula formation, and stricture recurrence.

Recent Findings

The surgical options for treatment of distal urethral strictures have changed throughout the years; however, there is no one universally accepted technique for their treatment. The current trend for treatment is shifting away from multi-staged procedures or the use of local skin flaps to single-stage transurethral procedures that utilize buccal mucosa with glans preservation.

Summary

This chapter will describe the evolution of distal urethral stricture treatments tracking gradual improvements and modifications over time. The different interventions include transurethral approaches, such as dilations and visual urethrotomy, meatotomy, and meatoplasty/urethroplasty techniques including genital skin flaps and single- and double-stage repairs with buccal mucosal grafts.

     

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.