Die Verwendung von Mundschleimhaut in der Harnröhrenchirurgie

Buccal mucosa grafts have proven reliable in urethral surgery. For augmentation urethroplasty, the graft can be used as a ventral or dorsal onlay. If the graft was used as an onlay, the results were much better than in substitution urethroplasty with the graft used as a tube. In patients with complex strictures or severe cases of hypospadias or epispadias, a two-stage technique using a buccal mucosa inlay graft can be applied. After 6 months, the well-revascularized buccal mucosa strip can be tubularized and covered with a tunica dartos or tunica vaginalis flap.In the future, for correction of larger defects, buccal mucosa cells can be cultured in vitro on biodegradable matrices. These larger buccal mucosa transplants could minimize the morbidity at the donor site. Future studies must clarify if the new technology of nanofibers can be of advantage by producing better matrices.     

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.     

Changing practice in anterior urethroplasty

OBJECTIVE: To describe our experience of penile urethral repair and reconstruction, cataloguing the change in practice from one-stage flap to two-stage free graft procedures for anterior urethroplasty. PATIENTS AND METHODS: Between January 1992 and December 1996, 79 patients underwent anterior urethroplasty. Of the 45 one-stage bulbar patch urethroplasties, 37 (76%) used buccal mucosal free grafts rather than flaps. Of the 34 penile urethroplasties, 26 (82%) (including all of the circumferential reconstructions) were two-stage procedures. RESULTS: Buccal mucosal free grafts were at least as good as local skin flaps for patch urethroplasty and two-stage repairs gave much better results than one-stage repairs for total circumferential reconstruction of the penile urethra. CONCLUSIONS: For a patch urethroplasty of an uncomplicated stricture in the bulbar urethra, buccal mucosal free grafts are now the material of choice. For a patch urethroplasty of an uncomplicated stricture in the penile urethra the Orandi procedure remains the 'gold standard'. For a circumferential repair of the urethra, particularly the penile urethra, a two-stage repair using a free graft gives better results than a one-stage repair using a flap.     

复杂性尿道下裂修复失败后的治疗

目的 探讨不同游离黏膜、带蒂皮瓣或二种组织拼接尿道成形术治疗复杂性尿道下裂修复失败后病例的效果.方法 采用3种游离黏膜或带蒂阴茎皮瓣尿道成形治疗尿道下裂修复失败后患者36例,其中带蒂阴茎皮瓣尿道成形7例,舌黏膜与阴茎皮瓣拼接重建尿道3例.结肠黏膜重建尿道2例,1条舌黏膜重建尿道9例,1条颊黏膜重建尿道7例,采用2条口腔内黏膜拼接重建尿道8例.阴茎用弹力绷带包扎4 d,每天用抗生素液冲洗尿道1次.结果 36例术后随访3～84个月,平均32.6个月.术后2～3周发牛尿瘘4例.术后2～3个月新尿道发生狭窄3例,其中吻合口狭窄1例.经尿道扩张5次后排尿通畅;尿道外口狭窄2例,经手术矫正后均排尿通畅,Q_(max)分别为37.3和28.7 ml/s.余者排尿通畅,尿线粗,Q_(max) 18.0～46.0 ml/s,平均26.8 ml/s.结论 舌黏膜与颊黏膜具有取材方便、创伤小的特点,较适合于尿道下裂修复失败后皮源少患者的尿道重建.     

Treatment of urethral defects: skin, buccal or bladder mucosa, tube or patch? An experimental study in dogs

PURPOSE: We studied 3 graft materials and 2 urethroplasty techniques in 24 adult male mongrel dogs. MATERIALS AND METHODS: The animals were divided into 2 equal groups. In group 1 a 4 cm. segment of perineal urethra was excised and tubed urethroplasty was performed using free full-thickness skin, buccal and bladder mucosa grafts in 4 dogs each. In group 2 a 4 cm. urethral strip was excised and onlay urethroplasty was performed using the same graft materials in 4 dogs each. Retrograde urethrography was done and the animals were sacrificed at week 12. Autopsy specimens were calibrated with a 10Fr catheter. Hematoxylin and eosin stained sections were examined. Masson's trichrome stain was used to determine the extent of fibrosis. RESULTS: Urethral stricture was diagnosed by radiology and confirmed by calibration in 8 of the 12 dogs (66%) in group 1 but in only 1 of the 12 (8%) in group 2 (p <0.004). Buccal mucosa grafts were associated with the lowest stricture rate of 12%, followed by 37% for bladder mucosa and 62% for skin (p <0.2). There was no difference in neovascularization among the 3 grafts. Graft shrinkage was less than 10% for buccal mucosa compared with 20% to 40% for skin and bladder mucosa. The shrinkage rate was similar for the onlay and tube techniques. The intensity of chronic inflammation and fibrosis was highest in the skin grafts. Circumferential fibrosis was noted in association with tubed urethroplasty but not with the onlay technique. CONCLUSIONS: The theoretical advantages of buccal mucosal grafts were pathologically demonstrated. When possible, grafts should be used as an onlay rather than as a complete tube.     

Urethral plate salvage with dorsal graft promotes successful penile flap onlay reconstruction of severe pendulous strictures

PURPOSE: A modified 1-stage penile flap onlay reconstruction is presented for patients with a long stricture in whom the urethral plate is deficient or absent. MATERIALS AND METHODS: Of 37 patients who underwent transverse penile island flap onlay urethroplasty 3 men and 1 boy required simultaneous augmentation (2) or replacement (2) of an inadequate urethral plate. The 15-year-old boy had persistent severe chordee after multiple hypospadias procedures. A dorsal buccal mucosal graft was used in 3 cases and cadaveric dermal graft was used in 1. The goal of dorsal graft application in each case was to create a uniform urethral plate 1 cm. wide to promote successful 1-stage penile flap onlay reconstruction. RESULTS: No patient has required further instrumentation and all void without difficulty. In the 15-year-old boy chordee has completely resolved. CONCLUSIONS: Using dorsal grafts to salvage an inadequate urethral plate during 1-stage penile island flap onlay reconstruction obviates flap tubularization.     

Buccal mucosal grafts: lessons learned from an 8-year experience

PURPOSE: We evaluated our 8-year experience with buccal mucosal grafts in complex hypospadias and epispadias repair. MATERIALS AND METHODS: We reviewed the records of 29 patients in whom a total of 30 buccal mucosal grafts were placed as part of urethral reconstruction between 1991 and 1999. At surgery 16 tubes and 14 onlays were constructed and 24 of 30 repairs involved the meatus. All patients were followed at least 6 months postoperatively (median 5.3 years). Beginning in 1995 meatal design was enlarged to a racquet handle shape and patients were asked to perform meatal self-dilation for 6 months postoperatively. RESULTS: Complications developed in 17 of our 30 cases (57%) and reoperation was done in 10 (33%). All complications were evident by 11 months postoperatively except 1 that presented as recurrent stricture disease at 3 years. Complications developed in 5 and 12 of 15 patients who underwent surgery between 1995 and 1999, and before 1995, respectively (p = 0.027). No patient has had meatal stenosis since 1995. Complications included meatal stenosis in 5 cases, stricture in 7, glanuloplasty, meatal and complete graft breakdown in 1 each, and fistula in 2. Onlays were more likely to result in stricture than tube grafts (6 of 14 cases versus 1 of 16, p = 0.034). CONCLUSIONS: The complication and reoperation rates of buccal mucosal grafts are 57% and 33% at 5 years of followup. Changes in meatal design and temporary postoperative meatal dilation have improved the outcome in the last 5 years. Buccal mucosa remains a good choice in patients who require extragenital skin for urethral reconstruction.     

Substitution urethroplasty with buccal mucosal-free grafts

PURPOSE: Buccal mucosal grafts and the Barbagli technique are recent developments in the treatment of urethral strictures. MATERIALS AND METHODS: We reviewed the results of and experience with urethroplasty using buccal mucosal graft in 128 patients. RESULTS: The re-stricture rate was 11% for patch grafts and 45% for tube grafts. There were no other complications. CONCLUSIONS: Buccal mucosal graft is at least as good as any other material for substitution urethroplasty with fewer complications. The 2-stage is more reliable than the stage 1 approach for circumferential reconstruction of the urethra.     

Failed hypospadias repair presenting in adults

OBJECTIVES: To evaluate the results of one-stage and multistage urethroplasty in adults with complications following multiple failed hypospadias repairs. METHODS: Sixty adults underwent reconstructive surgery of the following complications after hypospadias repair: stricture (34), residual hypospadias (26), fistula (18), meatal stenosis (11), penile curvature (9), hair (4), diverticula (2), and stone (1). A total of 36% of the patients had one complication and 64% had two or more complications. Twenty-nine patients underwent one-stage repair with buccal or skin grafts or direct repair, and 31 underwent multistage repairs with buccal or skin grafts. RESULTS: Mean follow-up was 33.8 mo. Of the 60 cases, 45 (75%) had a final successful outcome and 15 (25%) failed. One-stage repair provided 24 (82.7%) successes and 5 (17.3%) failures. Multistage repair provided 21 (67.7%) successes and 10 (32.3%) failures. Buccal mucosa grafts provided 81% of success in one-stage procedures and 82.3% in multistage procedures. Penile skin grafts provided 80% of success in one-stage procedures and 50% in multistage procedures. CONCLUSIONS: Adults with complications following childhood hypospadias repair are still a difficult population to treat with a high failure rate for reoperative surgery.     

The oral mucosa graft: a systematic review

PURPOSE: We provide the reader with a critical, nonbiased, systematic review of current and precedent literature regarding the use of oral mucosa in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias. MATERIALS AND METHODS: We reviewed pertinent English literature from January 1966 through August 1, 2006 via the databases MEDLINE/PubMed, the Cochrane Library, and EMBASE Drugs and Pharmacology regarding the use of oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias. Bibliographies of pertinent articles were explored for additional important literature. RESULTS: Data were stratified among studies that only used oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with stricture, and those that used oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with hypospadias/epispadias. Recipient site success in the reconstruction of defects associated with stricture was significantly associated with the location of graft placement (ventral vs dorsal, p <0.001) when an onlay graft was used. Hypospadias/epispadias recipient site success was significantly associated with the type of graft used (tube vs onlay, p <0.001), and by the site of oral mucosa harvest (labial vs buccal, p <0.001). Other perioperative and patient oriented variables were not significantly associated with success at the recipient site. CONCLUSIONS: The oral mucosa is a viable source of donor tissue displaying many characteristics of the ideal urethral graft. There are numerous variations of the oral mucosa graft urethroplasty technique. Herein comparisons are made.     

Complete repair of bladder exstrophy: management of resultant hypospadias

PURPOSE: In our hands complete primary repair (CPR) of bladder exstrophy results in hypospadias in two-thirds of boys. To our knowledge hypospadias repair following CPR of bladder exstrophy has not been reported previously. We report our experience with hypospadias repair following CPR of bladder exstrophy. MATERIALS AND METHODS: A total of 22 boys with bladder exstrophy underwent CPR using Mitchell's technique between November 1998 and January 2002. The procedure resulted in hypospadias in 15 boys (68%). The site of the meatus was distal penile in 5 patients, mid penile in 3 and proximal penile in 7. Hypospadias repair was performed in all 15 boys. The 5 patients with distal penile hypospadias underwent repair consisting of Thiersch-Duplay urethroplasty with dorsal incision in 3 and tubularized vertical island flap with glanular tunnel in 2. All patients with mid (3) or proximal (7) penile hypospadias underwent Mustarde repair with glanular tunnel. RESULTS: Followup ranged from 6 to 18 months (median 13). The Thiersch-Duplay procedure with dorsal incision resulted in fistula/stenosis in 2 of 3 boys. None of the remaining 12 boys with tubularized penile flap urethroplasty (tubularized vertical island flap or Mustarde) with glanular tunneling had development of fistula or stenosis. Complete degloving of the penis and penile skin redistribution were not necessary with the Mustarde technique. CONCLUSIONS: Thiersch-Duplay urethroplasty with dorsal incision does not seem to be a good option for hypospadias repair following CPR of bladder exstrophy. The use of penile skin as a tubularized flap with glanular tunneling seems to yield excellent functional/cosmetic results.     

颊黏膜在修复尿道下裂应用中的探讨

目的：探讨尿道下裂中应用颊粘膜进行尿道重建的可行性。方法：从2008年2月～2009年4月,我们在Snodgrass尿道成形术基础上,通过将游离的自体颊黏膜瓣形成新尿道镶嵌于劈开的＂尿道板＂的方法对2例阴茎型尿道下裂病例进行手术治疗并评价其效果。结果：病例术后均无明显的尿道狭窄和尿瘘发生,无尿道憩室形成和尿道口黏膜增生外翻。结论：自体颊粘膜作为尿道替代材料用于尿道下裂分期成形术是可行的。     

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.     

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.     

Use of buccal mucosal grafts in hypospadia-crippled adult patients

The buccal mucosa has begun to be used as a free graft in complex hypospadias repair gradually and successfully in recent years. However, there are limited experiences regarding use of the buccal mucosa in adult patients. In this study, the authors describe their experience using buccal mucosal grafts in hypospadias-crippled adult patients. Between March 1996 and February 2001, the buccal mucosa was used in 26 cases of complex hypospadias in which local penile skin was not present or it was insufficient for urethral repair. All patients were adults (age range, 17-24 y; average, 21 y). In these patients in whom penile skin was insufficient, urethral repair by buccal mucosa was planned, with the stipulation that at least 6 months had passed from the previous operation. The buccal mucosa has been applied to 23 patients alone and in combination with penile skin in three patients. After surgery, the patients were followed-up for 3 to 18 months (average, 12 mo). During the follow-up, fistula in the line of the proximal anastomosis, meatal stenosis, and the fistula together with meatal stenosis developed in nine (35%), four (15%), and two patients (7%), respectively. It is concluded that buccal mucosa is the free graft material that should be the first choice in complex hypospadias cases that are circumcised or undergo operation more than once and when the penile skin is not available.     

Current controversies in anterior urethral stricture repair: free-graft versus pedicled skin-flap reconstruction

Reconstruction of long anterior urethral strictures that cannot be excised and reanastomosed remains controversial. We critically reviewed the literature on free-graft and pedicled skin-flap urethroplasty to determine the optimal method of repair. Overall, free grafts were successful in 84.3% of cases and flaps, in 85.9%. Buccal mucosa grafts are the most successful method for reconstruction of bulbar urethral strictures. For strictures in the penile urethral or a compromised graft bed a distal penile skin flap is the most reliable and tested approach. Dorsal free-graft urethroplasty may be considered when penile skin deficiency prevents use of a flap. For the most complex strictures, in which a flap is not possible and the graft bed is of poor quality, a mesh graft in two stages may be the only option. Thus, for reconstruction of complex anterior urethral strictures, both free-graft and flap procedures remain indispensable.     

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.     

口腔粘膜游离移植再造尿道

目的：探讨采用口腔粘膜游离移植，对局部缺乏组织的尿道下裂行尿道再造的方法。方法：1998－2001年对25例患者应用口腔粘膜游离移植再造阴茎段尿道，半年后吻合瘘口。结果：1例一期术后并发感染，愈后无尿道狭窄，所有病例二期吻合瘘口后，再造尿道通畅。结论：口腔粘膜丰富的网状毛细血管网、韧厚的上皮层和相对较薄的皮下板层结构是移植成功的关键。以口腔粘膜游离移植行尿道再造是一种可行的方法。     

Buccal mucosal urethroplasty: is it the new gold standard?

Whilst techniques for urethral reconstruction have developed in the past few decades the quest for an ideal substitute continues. We critically review the literature on buccal mucosal grafts for substitution urethroplasty, to determine the efficacy and complications arising from its use. Buccal mucosal grafts have proved to be a versatile substitute for strictures attributable to a wide range of causes. Placing the graft dorsally appears to be more successful than ventrally and was successful in 96% of cases; after treating complex urethral strictures with two-stage procedures about a quarter of patients required a revision after the first stage with fewer complications then when skin was used as a substitute. Thus, buccal mucosa is most likely to become the new gold standard for substitution urethroplasty and longer term results with its use are eagerly awaited.     

8 cm以上复杂性尿道狭窄的外科治疗

目的探讨长段尿道狭窄手术方法的选择与疗效。方法对76例尿道狭窄8cm以上的患者采用不同尿道成形术式治疗,其中不同黏膜重建尿道42例（结肠黏膜26例,膀胱黏膜6例,口腔黏膜10例）;带蒂皮瓣一期尿道成形20例;尿道狭窄段切开、二期尿道成形（Johanson术）12例;阴茎段尿道与前列腺部尿道吻合、三期尿道成形术2例。结果术后初期（6个月内）排尿通畅67例（88％）,有并发症者10例。术后1年以上70例,其中获得随访51例,排尿通畅44例,有并发症者8例,其中采用带蒂皮瓣者发生尿道狭窄2例（18％,2／11）;Johanson术者发生阴茎弯曲2例（2／5）,其中1例成形段尿道内毛发生成和结石形成;采用口腔黏膜者发生尿道狭窄1例（1／7）,膀胱黏膜者发生尿道狭窄1例（1／3）,结肠黏膜者发生后尿道狭窄2例（9％,2／23）。结论口腔与结肠黏膜尿道成形对长段尿道狭窄是较理想的术式;结肠黏膜较适合在常规手术治疗失败后或复杂性尿道狭窄10cm以上的治疗。