Lingual mucosal graft substitution urethroplasty for anterior urethral strictures: our technique of graft harvesting

OBJECTIVE: To describe our technique of lingual mucosal graft harvesting for substitution urethroplasty and the complications encountered at the donor site. METHODS: Twenty-eight patients who underwent lingual mucosal graft urethroplasty between May 2006 and March 2007 were included in this study. TECHNIQUE: The site of the graft harvest is the lateral mucosal lining of the tongue. Graft harvesting is started from the posterior landmark of the graft on the left side of the tongue. It is continued across the tip of the tongue to the other side if lengthier graft is required. The graft harvesting site is simultaneously closed with continuous running suture using 4-0 polyglactin suture to achieve immediate and good homeostasis. RESULTS: Mean duration of follow up was 4.2 months. Average length of harvested graft was 6.5 cm. Mean harvesting time was 18 min. At the first postoperative day, 92% patients experienced pain at donor site and 24% had slurring of speech. By third postoperative day, >70% were free of pain and four had slurring of speech. By sixth postoperative day, none of the patient suffered pain. All the patients were able to resume oral fluid within 24 h, eat soft solid diet in 48-72 h and return to normal diet after 4-5 days of surgery. No patient suffered from difficulty in opening the mouth, salivation disturbances, peri-oral numbness or difficulty in protrusion of tongue. CONCLUSION: Lingual mucosal graft harvesting is a simple procedure, provides lengthy graft and is associated with minimal donor site complications.     

小肠黏膜下脱细胞基质修复前尿道狭窄的疗效分析

目的 探讨小肠黏膜下脱细胞基质(small intestinal submucosa,SIS)修复前尿道狭窄的可行性和有效性.方法 2009年6月至2010年8月采用4层SIS补片修复治疗尿道狭窄患者18例.患者年龄20～69岁,平均38岁;尿道狭窄段3.5～7.0 cm,平均4.6 cm;术前最大尿流率1.5～5.5 ml/s,平均3.8 ml/s.术中按需将SIS(长4.0～7.5 cm,宽 2.0 cm)植入尿道背侧缺损处,5-0可吸收线将SIS间断固定在阴茎海绵体上,SIS两侧与已剪开的狭窄段尿道作连续缝合,两端分别与尿道断端作间断吻合.结果 手术过程顺利,术后恢复好.随访6～18个月,平均10个月,患者未发生感染、排斥反应等并发症.17例排尿通畅,最大尿流率14.0～44.0 ml/s,平均25.4 ml/s.尿道造影显示尿道通畅;术后4、6周尿道镜检查示SIS移植物与周围组织分界清楚;术后14周尿道镜检查SIS已降解,修复段尿道与周围组织间限消失,黏膜光洁完整,管腔无明显狭窄;植入SIS部位活检显示黏膜表层为上皮细胞.1例尿道下裂术后患者术后5个月出现轻度尿道狭窄症状,行尿道扩张治疗.结论 利用SIS修复尿道狭窄具有创伤小、抗感染力强的特点,可作为组织工程尿道修复重建材料修复部分尿道狭窄患者.

Abstract：

Objective To investigate the feasibility of using small intestinal submucosa (SIS) graft for the repair of anterior urethral strictures. Methods From June 2009 to August 2010, 18 men (mean age, 38 yrs) with anterior urethral strictures underwent urethroplasty using a four-layer SIS as an onlay patch graft. SIS was used to augment the urethral caliber at the stricture site. The mean stricture length was 4.6 cm (range 3.5 to 7 cm). The pre-operative mean maximal flow rate was 3.8 ml/s (range 1.5 to 5.5 ml/s). The required SIS grafts (4 to 7.5 cm long and 2 cm wide) were positioned into the urethrotomy defect and were spread-fixed to the corpora cavernosa using 5-0 polyglactin interrupted sutures. Two apices of the graft were sutured to the proximal and distal apices of the urethrotomy with 5-0 polyglactin interrupted stitches. The margins of the opened urethra were sutured to the SIS patch with 5-0 polyglactin running sutures. Results The mean follow-up period was 10 mon. (range 6-18 mon.). No postoperative complication, such as infection or rejection related to the use of heterologous graft material was observed. Seventeen patients voided well postoperatively with the mean peak urine flow of 25.4 ml/s (14-44 ml/s). Cystoscopy revealed that at four weeks and six weeks, the SIS graft was well distinguishable from the normal surrounding tissue; and at 16 weeks, the urothelium was regenerated and the biomaterial was not distinguishable from the normal surrounding tissue. The squamosal epithelium was seen in the histological examination of the grafts. The remaining one patient with failed hypospadias developed a slight urethral narrowing at five months post-operatively and needed sound dilatations. Conclusions SIS matrix appears to be a safe and effective reconstructive material in selected urethral reconstructions.     

Ventral onlay graft bulbar urethroplasty using buccal mucosa

ObjectiveTo assess the ongoing role of ventral onlay oral mucosa free graft in the treatment of bulbar urethral stricture.MethodsDetailed review of technical consideration and outcomes from the author's institution along with review of other peer reviewed literature.ResultsOf 62 patients undergoing ventral onlay buccal mucosa urethroplasty, 19% had recurrence of stricture, and an additional 5% exhibited diverticulum formation. Complications were self-limited. Previously published case series and meta-analysis demonstrate similar results.ConclusionVentral onlay remains an effective and versatile part of the armamentarium for bulbar urethral stricture.     

尿道背侧颊黏膜镶嵌补片法治疗长段前尿道狭窄

目的 评价颊黏膜尿道背侧镶嵌技术尿道修复重建手术的有效性和安全性.方法 男性前尿道狭窄患者57例.平均年龄36(17～52)岁.尿道狭窄长度平均3.0(2.5～7.0)cm.颊黏膜取材长度平均4.0(3.5～8.0)cm,平均宽度2.3(I.8～2.5)am.57例均有经尿道内窥镜冷切电切手术史,其中1次手术史29例(51%),2次20例(35%),3次8例(14%),行耻骨上膀胱造瘘48例,9例采用尿道扩张维持.手术游离并旋转尿道,并于尿道背侧纵行切开,6-0可吸收线缝合颊黏膜与尿道切缘.保留尿管4周,拔管时行顺行尿道造影.患者排尿困难和尿线变细、尿道造影或尿道镜发现尿道管腔狭窄<16 F确定为尿道狭窄复发.结果 57例手术均成功,平均手术时间135(105150)min.平均随访11.2(1～23)个月.尿道通畅54例(95%),术后2～3个月复发3例(5%),狭窄部位均为远端的颊黏膜与尿道结合部,行尿道内窥镜冷刀切开,定期尿道扩张治疗.伤口感染3例,未发生尿瘘及尿道憩室.患者口腔疼痛持续2～5 d,平均2.3 d.术后无张VI困难、颊部麻木及腮腺导管梗阻等并发症发生,VI腔颊部均未见瘢痕形成.结论 VI腔颊黏膜尿道背侧镶嵌补片修复重建尿道,效果确切、并发症少、狭窄复发率低,是理想的长段前尿道狭窄的修复重建手段.     

Standing the test of time: the long-term results of urethroplasty

The principle indication for urethral surgery is stricture disease. There are a number of factors that influence the outcome of surgery including location of the stricture, stricture length, aetiology, previous surgery and selection of procedure. Outcomes for different techniques are summarised. The gold standard remains anastomotic urethroplasty, where appropriate, with patch urethroplasty or two-stage stage procedures for more complicated strictures especially the penile urethra.     

Dorsal onlay lingual mucosal graft urethroplasty for urethral strictures in women

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

OBJECTIVE

To describe the technique and results of dorsal onlay lingual mucosal graft (LMG) urethroplasty for the definitive management of urethral strictures in women.

PATIENTS AND METHODS

In all, 15 women (mean age 42 years) with a history suggestive of urethral stricture who had undergone multiple urethral dilatations and/or urethrotomy were selected for dorsal onlay LMG urethroplasty after thorough evaluation, from October 2006 to March 2008. After a suprameatal inverted‐U incision, the dorsal aspect of the urethra was dissected and urethrotomy was done at the 12 o’clock position across the strictured segment. Tailored LMG harvested from the ventrolateral aspect of the tongue was then sutured to the urethrotomy wound over an 18 F silicone catheter.

RESULTS

The preoperative mean maximum urinary flow rate of 7.2 mL/s increased to 29.87 mL/s, 26.95 mL/s and 26.86 mL/s with a ‘normal’ flow rate curve at 3, 6 and 12 months follow‐up, respectively. One patient at the 3‐month follow‐up had submeatal stenosis and required urethral dilatation thrice at monthly intervals. At the 1‐year follow‐up, none of the present patients had any neurosensory complications, urinary incontinence, or long‐term functional/aesthetic complication at the donor site.

CONCLUSION

LMG urethroplasty using the dorsal onlay technique should be offered for correction of persistent female urethral stricture as it provides a simple, safe and effective approach with durable results.     

Dorsal inlay graft urethroplasty for primary hypospadiac repair

OBJECTIVE: Tubularized incised plate urethroplasty has become a popular technique for repairing distal and proximal hypospadias in many institutions. Dorsal inlay graft urethroplasty has been used in our institution since 2003 to reduce the risk of meatal stenosis. In the present study, we evaluated the results of the dorsal inlay graft procedure. METHODS: A total of 28 patients with no deep groove and no severe curvature underwent one-stage urethroplasty using an inner preputial-based dorsal inlay graft. The medical records of all patients were retrospectively reviewed with regard to complication rate and cosmetic appearance. RESULTS: Mean patient age at surgery was 21 months (range, 14 months to 4.6 years). Preoperatively the urethral meatus was coronal in two cases, distal shaft in 17, proximal shaft in six and penoscrotal in three. Nine patients required testosterone therapy before surgery. Mean operative time was 200 min (range, 154-249 min). Mean length of inlay graft was 20.9 mm (range, 12-30 mm). In all patients, a straight penis was achieved without dorsal plication of the corposa cavernosa, and the neomeatus with a slit-like appearance was positioned at the glans tip. At a mean of 22 months of follow up, a urethrocutaneous fistula developed in only one patient (3.6%), requiring repair surgery 6 months after urethroplasty. No patient had meatal stenosis, neourethral stricture or urethral diverticulum along the inlay graft. CONCLUSION: Dorsal inlay graft urethroplasty is an effective method for hypospadiac repair and leads to good cosmetic outcome with low risk of complications.     

Use of overlapping buccal mucosa graft urethroplasty for complex anterior urethral strictures

Complex anterior urethral stricture disease typically manifests as a symptomatic, severely narrowed, long stricture (or multiple strictures) in which conventional excision and/or augmentation is not feasible. Overlapping buccal mucosal graft urethroplasty (OBMGU) is an innovative hybrid technique, combining the well-established principles of dorsal and ventral graft augmentation to allow single stage reconstruction of complex anterior urethral strictures. In this review, we discuss the rationale, techniques, and outcomes of OBMGU for complex anterior urethral strictures.     

显微外科技术纵形带蒂岛状包皮瓣一期修复尿道下裂

目的 探讨显微外科技术纵形带蒂岛状包皮瓣修复尿道下裂的临床效果.方法 伴明显阴茎下弯的尿道下裂患者42例.年龄1～19岁,中位6.4岁.阴茎头冠状沟型6例、阴茎体型28例、阴茎阴囊型8例.4倍显微镜下采用纵形带蒂岛状包皮瓣术式33例,纵形带蒂岛状包皮瓣联合阴囊纵隔皮瓣成形9例.42例重建尿道平均3.6(2.5～6.0)cm. 结果 一次手术治愈38例(90.5%).术后出现尿瘘1例,行尿瘘修补治愈;尿道口狭窄2例,尿道吻合口狭窄1例,行尿道扩张后治愈.41例获随访9～52个月,平均27个月,患者均符合尿道下裂治愈标准. 结论 显微外科技术纵形带蒂岛状包皮瓣行一期尿道下裂修复手术成功率高,并发症少,值得临床推广.     

保留尿道板手术修复尿道下裂术后尿瘘

目的 总结保留尿道板手术修复尿道下裂术后尿瘘的l临床经验.方法 尿道下裂术后尿瘘患儿224例.患儿术后时间均>6个月,尿瘘瘘口直径>1.0 cm.应用尿道板切开卷管尿道成形术(Snodgrass)102例,年龄2～16岁,平均3.7岁;Duplay尿道成形手术86例,年龄2～14岁,平均3.5岁;Onlay岛状包皮瓣尿道成形术修复20例;尿道口基底皮瓣法(Flip-Flap)修复16例.结果 224例术后随访均≥6个月.Snodgrass手术102例,成功86例(84.3%),发生尿道狭窄3例,尿瘘复发13例;Duplay手术86例,成功75例(87.2%),发生尿道狭窄2例,尿瘘复发9例.2组手术疗效比较差异无统计学意义(P>0.05).Onlay手术20例,成功19例,尿瘘复发1例.Flip-Flap手术16例,成功14例,尿瘘复发2例.结论 尿道下裂术后尿瘘修补方法应根据患儿的具体条件选择.Snodgrass尿道成形术成功率与Duplay手术相当,可以更多应用,保证阴茎外观满意.     

Management of adult anterior urethral stricture disease: nationwide survey among urologists in the Netherlands

Background

Adult anterior urethral stricture disease is most often treated with dilatation or direct vision internal urethrotomy (DVIU). Although evidence suggests that anastomotic urethroplasty for short bulbar strictures is more efficient and cost effective in the long term, no consensus exists. It is unclear by whom and how often urethroplasties are performed in The Netherlands and how results are being evaluated.

Objective

To determine national practice patterns on management of anterior urethral strictures among Dutch urologists. This information will help to define the nationwide need for training in urethral surgery.

Design, setting, and participants

We conducted a 16-question survey among all 323 Dutch urologists.

Results and limitations

The response rate was 74%. DVIU was practised by 97% of urologists. Urethroplasty was performed at least once yearly by 23%, with 6% performing more than five urethroplasties annually. In the group of urologists younger than 50 yr of age, 13% performed urethroplasty, with 3% of those performing more than five annually. In the case of a 3.5-cm-long bulbar stricture, DVIU was preferred by 49% of responders. Even after two recurrences, 20% continued to manage a 1-cm-long bulbar stricture endoscopically. Of responders, 79% believed that urethroplasty should be proposed only after a failed endoscopic attempt. Diagnostic workup and evaluation of success varied greatly.

Conclusions

Most Dutch urologists believe that urethroplasty is an option only after failed DVIU. Endoscopic procedures are widely used, even when the risk of recurrence is virtually 100%. The definition of success is hampered by nonstandardised methods of follow-up. Only a small group of mainly older urologists frequently performs urethroplasties. Training programmes seem necessary to guarantee a high standard of care for stricture disease in The Netherlands. A pan-European practice survey might be interesting to clarify the need for centralised fellowship programmes.     

Porcine small intestinal submucosa graft for repair of anterior urethral strictures

OBJECTIVES: We evaluated porcine small intestinal submucosa (SIS) used in the treatment of inflammatory, iatrogenic, posttraumatic, and idiopathic strictures of bulbar and penile urethra. Midterm maintenance of urethral patency was assessed. METHODS: Fifty patients aged 45-73 yr with anterior urethral stricture underwent urethroplasty using a porcine SIS collagen-based matrix for urethral reconstruction. Stricture was localized in the bulbar urethra in 10 patients, the bulbopenile area in 31 cases, and in the distal penile urethra in nine patients. All patients received a four-layered SIS patch graft in an onlay fashion. A voiding history, retrograde and antegrade urethrography, and cystoscopy were performed preoperatively and postoperatively. Failure was defined as stricture confirmed on urethrogram. RESULTS: After a mean follow-up of 31.2 mo (range: 24-36 mo), the clinical, radiological, and cosmetic findings were excellent in 40 (80%) patients. Restricture developed in one of 10 bulbar, five of 31 bulbopenile, and four of nine penile strictures. These all occurred in the first 6 mo postoperatively. All patients with recurrences needed further therapy, but there has been no additional recurrence observed to date. No complications such as fistula, wound infection, UTI, or rejection were observed. CONCLUSIONS: Use of inert porcine SIS matrix appears to be beneficial for patients with bulbar and bulbopenile strictures. Midterm results are comparable to skin flaps and mucosal grafts.     

长隧道带蒂包皮内板尿道成形术治疗阴茎体型尿道下裂的疗效分析

目的 探讨长隧道带蒂包皮内板尿道成形术治疗阴茎体型尿道下裂的疗效. 方法 2007年9月至2010年4月收治阴茎体型尿道下裂患儿28例,年龄1.5 ～6.0岁,平均2.0岁.均行长隧道带蒂包皮内板尿道成形术.尿道开口均位于阴茎体部,距离阴茎头顶端16 ～ 37 mm,平均25immn;分离尿道及纠正阴茎下曲后尿道缺损30 ～ 42 mm,平均38 mm.手术要点:沿尿道开口环形切开阴茎皮肤,分离至尿道板,横断尿道板,沿尿道板与海绵体之间分离隧道至阴茎头正中,隧道长度26～38 mm,平均33 mm.尿道开口至阴茎头之间全程由隧道贯通,尽量保持阴茎腹侧皮肤与组织完整,取带蒂包皮内板制作新尿道,将新尿道通过阴茎侧方深筋膜下通道转移至腹侧隧道进行吻合.术中人工勃起试验证实合并轻度阴茎下曲13例,无明显阴茎下曲15例. 结果 28例均一期修复成功,手术时间50～70 min,平均55min.随访时间6～31个月,平均20个月.28例患儿均排尿通畅,尿线粗直.尿道呈矢状开口于阴茎头正中,阴茎下曲纠正满意,外观好,未发生尿瘘或狭窄. 结论 长隧道带蒂包皮内板尿道成形术适用于无或合并轻度阴茎下曲的阴茎体型尿道下裂,尤其适合年龄小或阴茎体细小患儿,手术简单,效果好,外观满意.     

异种真皮去细胞基质在尿道重建中的临床应用

目的 观察异种真皮来源的去细胞基质移植物(acellular matrix graft,ACMG)作为尿道狭窄重建手术替代材料应用于临床的安全性与有效性.方法 将ACMG作为尿道重建的替代材料,观察尿路上皮细胞能否长入并形成通畅的新尿道以及有无排斥反应.采用ACMG治疗尿道狭窄病例10例,年龄20 ～ 62,平均36岁.狭窄长度3.0 ～15.0 cm,平均6.9 cm.术时采用狭窄段切除后ACMG尿道套入术或狭窄段切开后ACMG补片尿道修补术,术后6个月拔除尿管,观察该ACMG在人体中有无排斥反应及ACMG辅助尿道重建术的治疗效果. 结果 10例患者拔除尿管后均恢复排尿,尿道造影及尿道镜检查可见术后尿道连续性好,腔内黏膜连续.随访至术后18个月,出现尿道狭窄2例,经尿道内切开扩张后恢复正常排尿,其余患者均可通过尿道正常排尿. 结论 异种真皮ACMG应用于尿道成形术中具有生物相容性良好、能从解剖上和功能上修复尿道的优点,适用于复杂、长段尿道狭窄病例的成形手术.     

Augmented urethroplasty with pseudospongioplasty in the treatment of penile strictures

Strictures involving the penile urethra generally require tissue transfer techniques. Ventral graft placement usually is avoided in the penile urethra because of the relative paucity of viable corpus spongiosal tissue necessary for vascularization and support. Instead, grafts are commonly placed dorsally using either an onlay or inlay technique. However, the successful use of ventrally placed grafts in the penile urethra supported by a pseudospongioplasty has recently been reported. The incorporation of a pseudospongioplasty provides a well-vascularized milieu for successful graft take in the penile urethra. This technique incorporates periurethral flaps of tunica dartos and Buck’s fascia for graft coverage. Pseudospongioplasty in the penile urethra has been shown to have a similar efficacy to standard spongioplasty in the bulbar urethra. Additionally, pseudospongioplasty outcomes are comparable to other graft augmentation techniques performed in the penile urethra. In penile strictures, where there is a paucity of spongiosal tissue, pseudospongioplasty for coverage of a ventral graft is a reliable option.     

An experimental model for stricture studies in the anterior urethra of the male rabbit

In this study, an animal model was developed for the examination of urethral strictures (US). Through a resectoscope, a resection was made in the urethras of 15 male rabbits. After 30 days, the rabbits were evaluated with urethrography, impedance planimetry and either histology or the determination of collagen content. Fifteen rabbits serving as controls were evaluated in the same way. Three rabbits in the resection group and one in the control group died before evaluation. Urethrography demonstrated a stricture in the remaining 12 animals in the resection group. The urethras of the control animals were all normal. Impedance planimetry confirmed that the luminal cross sectional area (CSA) of the strictures was significantly smaller than the CSA of the corresponding part of the urethra in the control group. No difference in CSA was found 1 cm proximal to the stricture. The strictures consisted of densely woven collagen which sent tongues into the adjacent normal parts of the urethra. No difference in collagen content was found between the two groups either at the stricture site or 1 cm proximally. The described method of producing US in the rabbit model was very consistent with all operated animals developing a stricture. The model might prove valuable in evaluating new methods for the treatment of US.     

应用口腔颊黏膜Ⅰ期修复女童复杂性前尿道缺损(附3例报告)

目的：探索颊黏膜在修复女童复杂性前尿道缺损中的应用价值。方法：采用部分耻骨劈开联合阴道前庭切口，截取相应大小的口腔颊黏膜作管状成形I期修复女童前尿道缺损3例。结果：3例女童术后均排尿通畅，最大尿流率为l9．6—24．4m1／s，平均为20．5m1／s，尿道造影示尿道通畅。结论：口腔颊黏膜具有取材方便、对患者创伤小、抗感染能力强等特性，是一种较好的尿道替代材料，尤其适合尿道狭窄段＜5cm的患者。     

Oral mucosal grafts urethroplasty for the treatment of long segmented anterior urethral strictures

Objective  To evaluate the efficacy and safety of using oral mucosal grafts for urethroplasty in the treatment of complex segmented urethral strictures. Methods  Between January 2002 and January 2008, 25 cases of long or multi-segmented urethral strictures (10–18 cm, mean 11.72) were treated using combined two oral mucosal graft urethroplasty. Of the 25 patients, combined double buccal mucosal graft (BMG) urethroplasty was performed in nine patients, double lingual mucosal graft (LMG) urethroplasty in seven patients and combined lingual and buccal mucosal graft urethroplasty in nine patients. Results  Follow-up was obtained for 6–72 months (mean 26.83) post-operatively. Urethrocutaneous fistulas developed in two patients. Urethral strictures developed in one patient undergoing BMG urethroplasty; the patient underwent five urethral dilations, after which he voided well with a urinary peak flow of 26.4 ml/s. Meatal stenosis developed in one patient undergoing LMG and a second operation was required, after which the patient voided well (urinary peak flow of 28.7 ml/s). The other patients voided well and urinary peak flow rates ranged from 16.8 to 49.2 ml/s (mean 28.65 ml/s). Conclusion  Combined two oral mucosal grafts substitution urethroplasty is an effective technique for the treatment of long, segmented urethral strictures.