Buccal mucosa urethroplasty in anterior urethral strictures

Buccal mucosal graft can be used for succesfull repair in both pendulous and bulbar strictures. MATERIAL AND METHODS: We present our experience with buccal mucosal graft repair in 8 patients with onlay patch that varies from 4 to 16 cm. in length. Three pendulous, two bulbar and three panurethral strictures were repaired. These patients were observed for 36 to 60 months. RESULTS: No stricture recurrences were observed. Only one patient had lower lip paresthesia for six months.     

Outcome of dorsal buccal graft urethroplasty for recurrent bulbar urethral strictures

OBJECTIVE

To audit our results of dorsal buccal mucosal graft urethroplasty for recurrent bulbar urethral stricture disease and compare them with those from specialist centres.

PATIENTS AND METHODS

Data were collected prospectively on 52 men who had urethroplasty with ≥1 year of follow‐up; failure was defined as the need for further intervention.

RESULTS

The mean (range) age of the patients was 39 (19–61) years and 23 (45%) had an identifiable cause for their stricture. The mean (range) stricture length was 3.5 (1.5–6) cm and was associated with moderate or severe spongiofibrosis in 38 (73%) men. Ten (19%) men had minor complications after surgery. The mean (range) follow‐up was 34 (12–80) months, with the mean maximum urinary flow rate increasing from 6 to 24 mL/s after surgery. The surgery failed, requiring dilatation or urethrotomy, in seven (14%) men at a mean (range) of 25 (15–50) months after urethroplasty, giving an overall success rate of 86%.

CONCLUSION

This prospective audit of dorsal buccal patch augmentation urethroplasty for bulbar strictures shows an equivalent outcome to the standard set by the expert originators, suggesting that is transferable to less specialized centres. The efficacy, low complication rate, short hospital stay and general applicability of the technique encourage its use for all men with recurrent bulbar stricture disease, but formal comparison with other options in randomized trials, including cost‐effectiveness analysis, is needed.     

Scrotal island flap urethroplasty in the management of bulbar urethral strictures

We describe our experience with 20 patients undergoing 1-stage scrotal island flap urethroplasty for severe bulbomembranous stricture disease. While 16 patients achieved satisfactory results, 4 required revision for recurrent stricture, diverticulum or fistula. Use of hairless skin and aggressive tailoring of the flap are stressed to avoid the common complications of diverticulum, hair ball and stone formation. This highly vascularized pedicle represents a reasonable alternative to staged repair when local tissue scarring is great and free full thickness skin graft viability is questionable.     

Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction

PURPOSE: Buccal mucosa has been advocated as an ideal graft material for urethral reconstruction. We report our multicenter experience with buccal mucosa ventral onlay urethroplasty for complex bulbar urethral reconstruction in adults. MATERIALS AND METHODS: A retrospective analysis of patients who had undergone buccal onlay urethroplasty at 4 military medical treatment facilities participating in the Uniformed Services Urology Research Group was performed. The database generated included demographic data, genitourinary history, preoperative symptoms (American Urological Association symptom score), preoperative urinary flow rate, stricture length and operative statistics. Postoperative followup data included symptom score, flow rate, retrograde urethrogram results, and complications. RESULTS: A total of 53 patients (average age 32 years, range 17 to 64) underwent buccal mucosa graft urethroplasty between January, 1996 and March, 1998 for refractory strictures. Sixteen patients had undergone an average of 2.2 prior endoscopic procedures (range 1 to 7). Average stricture length was 3.6 plus or minus standard deviation 1.8 cm. (range 2 to 7.5) as measured on preoperative retrograde urethrogram. Followup averaged 25 months (range 11 to 40 months). Average symptom scores decreased from 21.2 (range 14 to 33) preoperatively to 5.4 (range 3 to 8) postoperatively (p <0.001). Average peak urinary flow rates increased from 7.9 preoperatively to 30.1 ml. per second postoperatively (p <0.001). Postoperative retrograde urethrograms were available for 34 patients and were normal in 24. The overall complication rate was 5.4%. Three patients required endoscopic incisions. One patient has a recurrent narrowing and treatment is considered a failure. There were 4 sacculations (7.5%) and 6 narrowings, 3 of which required further treatment. Of the patients 50 required no additional procedures (94.3%). CONCLUSIONS: Buccal mucosa grafts used as a ventral onlay for bulbar urethral reconstruction yield reproducibly excellent results with minimal morbidity and low complication rates. Longer followup will be required to confirm the durability of our results.     

Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures

OBJECTIVES: Since the resurgence in the use of buccal mucosa (BM) in substitution urethroplasty in the late 1980s and early 1990s, there has been controversy as to which surgical technique is the most appropriate for its application.METHODS: The authors performed an updated literature review. Several centres have published widely on this topic, and the points considered include the use BM in dorsal onlay grafts, ventral onlay grafts, and tubularised grafts and the role of two-stage procedures.RESULTS: In experienced hands, the outcomes of both dorsal onlay grafts and ventral onlay grafts in bulbar urethroplasty are similar. The dorsal onlay technique is, however, possibly less dependent on surgical expertise and therefore more suitable for surgeons new to the practice of urethroplasty. The complications associated with ventral onlay techniques can be minimised by meticulous surgical technique, but in series with longer follow-up, complications still tend to be more prevalent. In penile urethroplasty, two-stage dorsal onlay of BM (after complete excision of the scarred urethra) still provides the best results, although in certain circumstances a one-stage dorsal onlay procedure is possible. In general, ventral onlay of BM and tube graft procedures in the management of penile strictures are associated with much higher rates of recurrence and should therefore be avoided.CONCLUSIONS: In experienced hands the results of the ventral and dorsal onlay of BM for bulbar urethroplasty are equivalent. Two-stage procedures are preferable in the penile urethra, except under certain circumstances when a one-stage dorsal onlay is feasible.     

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。     

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.     

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.     

One-stage urethroplasty for bulbomembranous urethral strictures

Summary A total of 23 patients with bulbomembranous urethral strictures (16 after pelvic fractures, 4 following direct perineal trauma, 3 after catheter drainage) were treated with a perineal one-stage anastomotic urethroplasty. The length of the stricture did not exceed 2 cm. The overall final success rate amounted to 95.6%. The one-stage perineal approach is recommended for short strictures of up to 2 cm in length, if mobilization of the distal urethra is possible and the periurethral scar tissue can be resected.     

Non-transecting bulbar urethroplasty using buccal mucosa

Augmentation urethroplasty using oral mucosal graft has become the standard surgical treatment of long bulbar strictures. In very tight strictures the urethral plate is narrowed to the extent that an almost circumferential substitution with oral graft is necessary, with suboptimal results. If the obliterative segment within a longer stricture is short it is possible, through a dorsal stricturotomy, to excise it in a non-transecting manner, leaving the ventral spongiosum intact and anastomose the mucosal edges to reconstitute the urethral plate to an adequate calibre. The stricturotomy is subsequently augmented with an oral mucosal graft. We describe this technique as the augmented non-transecting anastomotic bulbar urethroplasty. It also allows for use of a narrower and shorter graft. In our hands this procedure is associated with a 100% radiological success rate and a 95% patient satisfaction rate at a mean follow-up of 14.8 months (5.7–52.6 months).     

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.