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RESEARCH ARTICLE
Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 47-51
 

Single stage substitution urethroplasty using buccal mucosa graft in management of stricture urethra


Gandhi Medical Collage, Bhopal, India

Correspondence Address:
M C Songra
Gandhi Medical Collage, Bhopal
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Buccal mucosa graft and the Berbaglis technique are recent development in treatment of urethral stricture. We report results of 14 patients who were managed by single stage substitution urethroplasty using buccal mucosa graft.
Patients and Methods: From July 2002 to June 2004, 14 patients of mean age 27.02yrs (range 20 to 54) underwent dorsal onlay graft urethroplasty (Simple onlay in 12 patients and augmented type in 2 patients). All patients were evaluated preoperatively and postoperatively with uroflowmetry, retrograde and voiding urethrogram.
Results: Overall success rate was 85.71% and only 2 patients had restricture. Out of 14 patients 3 patients had leak at repair site which was managed conservatively.
Conclusion: Dorsal onlay graft urethroplasty is a versatile technique. The intrinsic properties of buccal mucosa also make it a better substitute for urethroplasty.


Keywords: Urethra, Urethral stricture, Urethroplasty, Buccal mucosa


How to cite this article:
Songra M C, Kerketta A, Dua R. Single stage substitution urethroplasty using buccal mucosa graft in management of stricture urethra. Indian J Urol 2004;20:47-51

How to cite this URL:
Songra M C, Kerketta A, Dua R. Single stage substitution urethroplasty using buccal mucosa graft in management of stricture urethra. Indian J Urol [serial online] 2004 [cited 2019 Nov 13];20:47-51. Available from: http://www.indianjurol.com/text.asp?2004/20/2/47/37168



   Introduction Top


This study was conducted in Department of General Surgery, Hamidia Hospital, Bhopal in July 2002 - June 2004. 14 patients underwent a single stage substitution urethroplasty using buccal mucosa graft. All patients were evaluated by preoperative and postoperative urethrogram and Uroflow study and were followed using Uroflow study. Success rate of 85.71% was achieved.

Stricture excision and anastomosis repair is appropriate technique for stricture less than 2cms. Long strictures have been approached with alternative solutions including excision of stricture, pedicle skin flap using local skin orfree graft. Penile and scrotal skin or foreskin pedicle graft in reconstructive surgeries of genitourinary malformations doesn't always provide satisfactory results when used for urethral stricture. For this reason, the use of free grafts has been encouraged. Experience in this field include use of genital (penile or prepuce) as well as extragenital grafts (postauricalar, groin, buttock and upper arm skin) and bladder mucosa. The complications that have arisen using these kinds of grafts are meatal prolapse, scar tissue stenosis and urethrocutaneous fistula. Thus in recent years there has been renewed interest in buccal mucosa graft, introduced in field of urology by Hurnby in 1941 to correct urethrocutneous fistula and subsequently used in correction of urogenital malformation as well as in management of posttraumatic iatrogenic and inflammatory urethral stricturesl. The fundamental advantages of using buccal mucosa graft rather than other tissue are thickened high elastic fiber content of epithelium and thinness of laminapropria.


   Patients and Methods Top


14 patients of mean age 27.02 yrs (range 20 to 54) underwent dorsal onlay graft urethroplasty. Etiology of structure was traumatic in 7 patients, infective in 5 patients and idiopathic in 2 patients [Table - 1]. The mean stricture length was 8.06 cms (range 5-18 cm.). Simple onlay graft urethroplasty was done in 12 patients and augmented type urethroplasty in remaining 2 patients.

The inner aspect of cheek was the preferred donor site in area just below Stenson's duct. With patient under epidural anesthesia a perineal midline incision was made. Urethra was mobilized completely from corpora cavernosa and rotated 180 degree. The stricture segment was identified and opened along its dorsal surface. Dorsal urethrotomy was extended proximal and distal to stricture until healthy corpus spongiosum was encountered. In 12 patients the free graft was simply onlaid on dorsal urethrotomy while, in remaining 2 patients stricture segment was excised and ventral half of urethral circumference was restored by end to end anastomosis, applying the graft to close dorsal hemicircumference (Augmentation roof strip procedure). In either circumstances graft was sutured to corporeal bodies and quilted [Figure - 2] in place with chromic 4-0 stitches 0.5 cms. apart. The urethra was then sutured to graft with vicryl 4-0 stitches in continuous manner [Figure - 3]

Buccal mucosa graft was harvested under short GA with transnasal intubation. A solution of normal saline with adrenaline 1:50,000 was injected submucosally at donor site. This reduces the bleeding potential and also elevates the graft from underlying fat to provide a plane of di$.ection. A graft of mean length 8.06 cms was harvested ant9 donor site was repaired. Defatting of graft was done and all underlying fibrovasculartissue was removed.

16F Foleys catheter was kept perurethrally in postoperative period for 2 wks in 6 patients and for 3 weeks in other 8 patients.


   Result Top


Regarding donor site, the patients began oral fluids on the next day. Complete healing occurred after 1 week with minimal scarring. Most common complication was wound infection [Table - 2], which occurred in 6 patients (42.8%). All these wounds were managed by simple dressing. Leak was evident in postoperative urethrogram in 2 out 6 patients (33.3%) in which catheter was removed after 2 weeks and only 1 out of 8 (12.5%) patients in which catheter was removed after 3 weeks. All these patients were recatheterised for further 2 weeks. None of these patients had any evidence of leak in repeat postoperative urethrogram.

After removal of catheter there was marked objective improvement in urinary stream as evidenced by uroflowmetry as well as subjective improvement. Two patients (42%) had recurrent stenosis [Table - 2] of the proximal extremity of repair after 8 and 10 months, which might be an extension of original pathological condition. Both of these patients were treated by OIU & did not require any further intervention in follow-up. Till last follow-up all patients were voiding well with a peak flow rates > 15 ml / second. Post void dribbling occurred in only 1 patient (7.14%). No patient had any complication like urethrocutaneous fistula, sacculation at repair site (common in ventral onlay procedure) and meatal prolapse (commonly associated with Bladder mucosa graft).


   Discussion Top


The use of buccal mucosa for urethral stricture repair is promising. Use of Buccal mucosa for urethral stricture in adults was introduced in 1992. El Kasaby et al reported a success rate of 90% with buccal mucosa urethroplasty [9] .

The problems associated with free skin graft are high incidence of restricture formation, shrinkage of graft and keloid formation at donor site. Use of bladder mucosa is also difficult in patients with previous bladder operation chronic cystitis or even long term SPC. Based on these complications of free skin and bladder mucosa graft we believe that, buccal mucosa graft is a better option. The material has been noted to retain elasticity of virgin tissue. Buccal mucosa at meatus is resistant to air. Mucus secretion from buccal mucosa seems to provide suitable dampness for meatus. Buccal mucosa is also resistant to skin disease like BXO, making its use in stricture related to such disease [3] .

The dorsal onlay graft procedure introduces some advantages over traditional ventral onlay graft urethroplasty [5] . The graft is fixed to underlying corporeal bodies, which has excellent blood supply and provides good mechanical support. The spreading of graft making use of its tensile strength, on corporeal bodies reduces the risk of graft shrinkage and chordee. Dorsal graft bed also avoids the problem of sacculation. By interposing the graft between urethra and corporeal bodies, fistula formation appears to be limited.


   Conclusion Top


In conclusion, we feel that the buccal mucosa onlay graft is currently the optimal method of substitution urethroplasty for majority of patients with stricture urethra. Although early results are favorable, the role of buccal mucosa for urethral reconstruction will be better defined in the future.[10]


   Acknowledgement Top


We are greatfull to the Dean, Gandhi Medical College and Hamidia Hospital Bhopal for allowing as to publish this paper. We are also thankful to Dr. S. S. Pal Assistant Professor Hamidia Hospital Bhopal for their help and suggestions from time to time.

 
   References Top

1.Augostino Meneghani et al. Bulbar urethral stricture with Buccal Mucosa graft urethroplasty. Eur. Urol. 2001; 39: 264-267.  Back to cited text no. 1    
2.Andrich DE, Leach CJ, Mundy AR. The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra. BJU Int. 2001; 88(4) : 385-389.  Back to cited text no. 2    
3.Andrich DE, Mundy AR. Substitution urethroplasty with buccl mucosal-free grafts. J Uol, 2001; 165(4) 1131-1134.  Back to cited text no. 3    
4.Barbagli G, Palminteri E, Lazzeri M, et al. Long-term outcome of urethroplasty after failed urethrotomy versus primary repair. J Urol. 2001; 165(6 pt 1) : 1918-1919.  Back to cited text no. 4    
5.Barbagli G, Selli C, di Cello V, et al. A one-stage dorsal free-graft u reth roplasty for bulbar urethra I strictures. Br J Urol, 1996; 78(6) : 929-932.  Back to cited text no. 5    
6.J. Duckettetal. Buccal Mucosal Urethral replacement. J. Urol. 1995; 153: 1660-1663.  Back to cited text no. 6    
7.S.N.Venn and A.R.Mundy. Early experience with the use of buccal mucosa for substitution urethroplasty Br. J. Urol. 1998, 81, 738-740.  Back to cited text no. 7    
8.Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adust bulburethral strictues. J Urol. 1998; 160(4) : 1307-1309.  Back to cited text no. 8    
9.Vito Pansadoro, Palio Emiliozzi and Marco Grafi. Buccal mucosa urethroplasty for treatment of Bulbar urethral strictures. J. Urol 1999, Vol. 161, 1501-1503.  Back to cited text no. 9    
10.D.Filipas, U.Wahlmann, R.Hohenfellner. History of oral mucosa, Eur. Urol. 1988; 34: 165-168.  Back to cited text no. 10    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]



 

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    Abstract
    Introduction
    Patients and Methods
    Result
    Discussion
    Conclusion
    Acknowledgement
    References
    Article Figures
    Article Tables

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