|Year : 2006 | Volume
| Issue : 2 | Page : 113-117
Reconstruction of the bulbar urethra using dorsal onlay buccal mucosal grafts: New concepts and surgical tricks
Guido Barbagli1, S De Stefani2
1 Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy
2 Department of Urology, University of Modena-Reggio Emilia, Modena, Italy
Center for Urethral and Genitalia Reconstructive Surgery, Via Frà Guittone, 2 52100 Arezzo
| Abstract|| |
Buccal mucosa onlay graft urethroplasty represents one of the most widespread methods for the repair of strictures in the bulbar urethra, because of its thick and highly vascular spongiosum tissue. Recently the location of the patch has become a contentious issue, since we described our original techniques of dorsal onlay graft urethroplasty. The design rationale for this approach was based on the concept that the corporeal body remains a healthy host for receiving a free transplanted tissues. Moreover, graft fixation onto a defined surface may decrease graft shrinkage and sacculation. The success rate using buccal mucosa grafts for the repair of bulbar urethral strictures has generally been high with dorsal or ventral onlay grafts or using an augmented roof-strip anastomotic urethroplasty. We describe here the fundamental concepts of the bulbar urethra reconstruction using buccal mucosal grafts, presenting a new surgical technique of dorsal onlay buccal mucosa graft urethroplasty using fibrin glue.
Keywords: Bulbar urethral, buccal mucosa, fibrin glue, graft, urethral reconstruction, urethroplasty
|How to cite this article:|
Barbagli G, De Stefani S. Reconstruction of the bulbar urethra using dorsal onlay buccal mucosal grafts: New concepts and surgical tricks. Indian J Urol 2006;22:113-7
|How to cite this URL:|
Barbagli G, De Stefani S. Reconstruction of the bulbar urethra using dorsal onlay buccal mucosal grafts: New concepts and surgical tricks. Indian J Urol [serial online] 2006 [cited 2013 May 22];22:113-7. Available from: http://www.indianjurol.com/text.asp?2006/22/2/113/26563
| Introduction|| |
Numerous surgical techniques have been described to repair bulbar urethral strictures, according to the stricture length and characteristics (1) including end-to-end anastomosis, augmented roof strip anastomotic urethroplasty, onlay repair using flap or graft and multi-staged procedures. Short bulbar strictures, ranging from 1 to 2 cm, are generally managed by end-to-end anastomosis (2) while an augmented roof-strip anastomotic urethroplasty is suggested for strictures ranging from 2 to 3 cm in length.,,, Strictures longer than 3 cm are generally managed using penile skin or buccal mucosa transfer procedures accomplished in a variety of ways, including dorsal or ventral onlay graft urethroplasty.,,,,,, Finally, in patients with strictures longer than 6 cm involving both penile and bulbar urethra or associated with local adverse conditions, a multi-stage urethroplasty or mesh graft urethroplasty is mandatory.,
The use of transplanted buccal mucosa graft, still represents the most widespread method for the repair of bulbar urethral strictures. The new technique of dorsal onlay buccal mucosa graft urethroplasty using fibrin glue that we present here, is simple, reliable and reproducible in the hands of any surgeon, based on sound anatomic principles and is able to be performed with readily available surgical instruments.
| Preoperative evaluation|| |
The clinical history and the medical charts of the patient are reviewed in order to evaluate the presence of previous perineal blunt trauma or repeated failed urethrotomy or urethroplasty and the genitalia are carefully inspected to exclude the presence of Lichen sclerosus disease.
Preoperative retrograde urethrography is mandatory to evaluate the site, number and length of stricture and voiding cystourethrography is useful in evaluation of the continence of the bladder neck and in evaluation of the urethral dilation proximally to the stenosis. Sonourethrography and urethroscophy are suggested to collect more detailed information on the stricture characteristics. Patients are fully informed that bulbar urethroplasty is a safe procedure as far as sexual function is concerned.
The patient's clinical history as well as the etiology of stricture and its location and length must be carefully examined to better define the characteristics needed in the buccal mucosa graft. Patients who currently have an infectious disease affecting the mouth (such as candida, varicellavirus or herpes virus) or who have had previous surgery in the mandibular arch that does not allow the mouth to be opened wide or who play wind instruments, are informed that genital or extra genital skin will be used for urethroplasty.
Three days prior to surgery, the patient should begin using clorhexidine mouthwash for oral cleansing and continue using it for 3 days after surgery. A broad-spectrum antibiotic is administered intravenously during the procedure and for 3 days afterward.
Cheek harvest technique
The patient is intubated through the nose, allowing the mouth to be completely free. The patient is draped in 2 separated parts and 2 surgical teams work simultaneously. Each team has its own set of surgical instruments, including suction and bipolar cautery.
By using a mouth retractor that has its own light, only one assistant is needed to harvest buccal mucosa. The inner mucosal surface of the right cheek is prepared and disinfected and stay sutures are placed in the external edge of the cheek to keep the buccal mucosa stretched. The Stensen's duct, located at the level of the second molar is identified and the desired graft size is measured and marked in an ovoid shape. Lidocaine HCL-1% with epinephrine (1:100,000) is injected along the edges of graft to enhance hemostasis.
The outlined graft is sharply dissected and removed. The donor site is carefully examined for bleeding and is closed with 4-zero polyglactin sutures. When necessary, another graft may be harvested from the left cheek, using the same technique. The graft is stabilized on a silicone board using insulin needles. After careful deflation with microsurgical instruments, the graft is tailored according to site, length and stricture characteristics. An ice bag is applied to the cheek to avoid pain and hematoma formation.
| Dorsal onlay buccal mucosa graft urethroplasty using fibrin glue|| |
Methylene blue is injected into to urethra to better define the urethral mucosa involved in the disease. A midline perineal incision is made, the bulbo-cavernous muscles are separated and the distal part of stenosis is identified using a 16 Fr. catheter with soft round tip. The bulbar urethra is dissected from the corpora cavernosa, rotated 180 degrees and the dorsal urethral surface is fully exposed and longitudinally opened [Figure - 1]. The opened urethra is moved on the right side and 2 ml of fibrin glue are injected over the corpora cavernosa [Figure - 1]. The buccal mucosa graft is spread fixed over the fibrin glue bed [Figure - 2]. Two interrupted 5-zero polyglactin sutures were used to stabilize the apex of the graft to the corpora cavernosa. The apex of the distal and proximal urethral incision are sutured to the apex of the graft [Figure - 3]. The urethra is rotated over the graft [Figure - 4]. Three interrupted 4-zero polyglactin sutures for each side, were used to stabilize the urethral margins to the corpora cavernosa over the graft [Figure - 5]. At the end of the procedure, the graft is completely covered by the urethra and 2 ml of fibrin glue was injected over the urethra to prevent urinary leakage [Figure - 5]. Foley 16 Fr. silicone catheter was left in place. A small suction drainage was left in place for one day.
Augmented roof-strip anastomotic urethroplasty using dorsal onlay buccal mucosa graft and fibrin glue
Methylene blue is injected into the urethra to better define the urethral mucosa involved in the disease. A midline perineal incision is made, the bulbo-cavernous muscles are separated and the distal part of stenosis is identified using a 16 Fr. catheter with soft round tip. The urethra is completely transected at the level of the stricture and the urethral edges are freed from the underlying corpora cavernosa. Two ml of fibrin glue was injected over the corpora cavernosa. The buccal mucosa graft was spread- fixed over the fibrin glue bed. Two interrupted 5-zero polyglactin sutures were used to stabilize the apex of the graft to the corpora cavernosa. Three interrupted 5-zero polyglactin sutures were used to stabilize the wide distal and proximal urethral incision to the graft. The left urethral mucosal margin was stabilized to the left side of the graft. A Foley 16 Fr. silicone catheter is inserted and the urethra is rotated back to its original position. The right urethral margin is stabilized to the right side of the graft. At the end of the procedure, the grafted area is entirely covered by the urethra. Two ml of fibrin glue was injected over the urethra to prevent urinary leakage. A small suction drainage was left in place for one day.
| Postoperative care|| |
The patient initially consumes a clear liquid diet and ice cream before advancing to a soft, then a regular diet. The patient ambulates on the first postoperative day and is discharged from the hospital 3 days after surgery. All patients receive intravenous broad-spectrum antibiotics postoperatively and are maintained on oral antibiotics until the catheter is removed.
In bulbar urethroplasty, the Foley silicone catheter is 14 Fr. with grooves to facilitate the urethral discharge from the meatus. Suprapubic urinary drainage is unnecessary. Two ice bags are immediately applied on the cheek, perineum and genitalia to reduce edema, pain and hematoma and to reduce nocturnal erections. The patient is discharged from hospital 3 days after surgery. After 3 weeks, the catheter is removed and voiding cystourethrography is obtained at same time.
Minor early complication is urethrorrhagia, due to the nocturnal erection. Later minor complications are temporary numbness, dysesthesia into to perineum and scrotal swelling.
Reports of complications after buccal mucosa harvesting in the literature are few, but include Stensen's duct damage, intraoperative bleeding, facial hematoma, infection (rare), subjective local disturbance, neural damage (paresthesia from "lungobuccale" or "mentoniero" nerve), retraction from scar (lip/cheek distortion and limited mouth opening. In our experience, from 1997 to 2003, on 650 buccal mucosa graft harvesting procedures (mean follow-up, 12 months), we have had 1 facial hematoma requiring emergency evacuation, 1 cheek granuloma requiring surgical ablation and 2 lip distortion and /or dysesthesias (unpublished data).
| Discussion|| |
1. Ventral vs. dorsal graft
Buccal mucosa graft onlay urethroplasty represents one of the most widespread methods for the repair of strictures in the bulbar urethra, because of its thick and highly vascular spongiosum tissue. Recently, the location of the graft has become a contentious issue since we described our original techniques of dorsal onlay graft urethroplasty. The design rationale for this approach was based on the concept that the corporeal body remains a healthy host for receiving a free buccal mucosa graft., Moreover, graft fixation by suture onto a defined surface may decrease graft shrinkage and sacculation., Success with buccal mucosa grafts for repairing bulbar urethral strictures has generally been high with dorsal or ventral onlay grafts.,,,,,,,,,
We retrospectively reviewed outcome analysis of 50 patients who underwent 3 types of urethroplasty with the buccal mucosal graft placed on the ventral, dorsal or lateral surface of the bulbar urethra. Out of 50 cases 42 (84%) were successful and 8 (16%) failed. The 17 ventral grafts provided success in 14 cases (83%) and failure in 3 (17%). The 27 dorsal grafts provided success in 23 cases (85%) and failure in 4 (15%). The 6 lateral grafts provided success in 5 cases (83%) and failure in 1 (17%). Failures involved the anastomotic site (distal in 2 and proximal in 3) and the whole grafted area in 3 cases. They were treated with urethrotomy in 5 cases and 2-stage urethroplasty in 3 cases. In our experience, the placement of the buccal mucosa grafts into the ventral, dorsal or lateral surface of the bulbar urethra showed the same success-rates (83 to 85%) and the outcome was not affected by the surgical technique. Moreover, stricture recurrence was uniformly distributed in all patients.
Recently, we have developed a new interesting step in the use of our dorsal onlay graft urethroplasty, using a fibrin glue to fix the graft to albuginea of corpora cavernosa. The use of fibrin glue avoids the necessity of numerous interrupted stitches to fix the graft: this is tedious and time-consuming step in onlay urethroplasty. Moreover, the apposition of the graft and its adhesion to the corpora cavernosa can be simplified by the use of fibrin glue that allows an ideal fixation of the graft to its vascular bed and therefore a better revascularization of the transplanted tissue. The tenacious adhesion of the graft keeps itself widely open reducing the risk of sacculation and shrinkage, allowing the surgeon to perform an easier anastomosis between the graft and the urethral margins. Fibrin glue shortens the times of revascularization of the graft because fibrin clot represents the first ring of a chain of events, which rules the process of revascularization of any free graft (followed by imbibition and inosculation). Experimental works in the rat documented a better healing and smaller shrinkage of free skin graft when fibrin glue was utilized.
2. Excision of the stricture vs. simple augmentation of the stricture
In 2004, Delvecchio et al suggested that the use of augmented roof-strip anastomotic urethroplasty using incorporation of the graft onlay in receiving urethral plate is less successful, either because of the inherent deterioration of transferred tissues exposed to urine or to the fact that the onlay is performed to a densely spongiofibrotic area, generally at the location of origination of the stricture disease, that is unsuitable for simple onlay grafting. These authors propose always the excision of this area, followed by direct reanastomosis of the floor strip and onlay of the adjacent "better" stricture, whatever its length. The authors show that this technique provide only 5, 2% of failures in 38 patients, compared with 9% of failures in 11 patients who underwent a simple augmented graft urethroplasty without excision of the strictured tract and conclude that excision of the worst segment of stricture (up to 2 cm) avoids long onlay to a poor urethral bed where failure often occurred at the location of the smallest stricture caliber.
Recently, we retrospectively reviewed 107 patients undergoing surgical reconstruction for bulbar urethral strictures between 1994-2004 (data submitted for publication). Mean patient age was 44 years. 95 patients underwent augmented graft urethroplasty and 12 patients underwent anastomotic graft urethroplasty. Out of 107 patients, 85 (80%) were considered success and 22 (20%) were considered failures. 75 of 95 augmented graft urethroplasty were successful (79%) and 20 (21%) failures. 10 of 12 anastomotic graft urethroplasty were successful (84%) and 2 (16%) failures.
3. Penile skin vs. buccal mucosa graft
Buccal mucosa is become a most popular substitute material in the treatment of anterior urethra stricture disease and its success is well documented in numerous series of patients who underwent bulbar urethra reconstruction. Prior to the use of buccal mucosa as substitute material, penile skin was a substitute material currently suggested for anterior urethroplasty. But buccal mucosa is really superior to penile skin? Alsikafi et al compared the outcomes of 95 buccal urethroplasty and 24 penile skin graft urethroplasties in an effort to answer the question if buccal is really best. The overall success rate of penile skin urethroplasty was 84% with a mean follow-up of 201 months, while the success rate of buccal urethroplasty was 87% with a mean follow-up of 48 months and no statistically significant difference was found between the two groups. In conclusions penile skin and buccal mucosa are excellent materials for substitution urethroplasty with comparable success rate, though penile skin appears to have a longer follow-up.
At our centres, a total of 95 consecutive patients, average age 44 years, range 17 to 79, underwent bulbar urethra reconstruction between January 1994 and December 2004 for urethral strictures., In 45 patients the stricture was managed using penile skin as substitute material and in 50 patients the stricture was managed using buccal mucosa s substitute material. 33 of 45 penile skin urethroplasty were successful (73%) and 12 (27%) were failures. 42 of 50 buccal mucosa urethroplasty were successful (84%) and 8 (16%) were failures. The skin graft urethroplasty showed a higher failure rate (27%) compared to buccal mucosa (16%). However, the penile skin group of patients had a longer follow-up (mean 71 months) when compared with the buccal mucosa group of patients (mean 42). Moreover, the penile skin showed a higher number of failures involving the entire graft area (17 vs. 6%), requiring a surgical revision using a multi-stage procedure.
Finally, in patients requiring anterior urethroplasty, the use of buccal mucosa avoid cosmetic disadvantages and consequences caused by the use of genital skin, because it is readily available in all patients with a concealed donor site scar. Moreover, the elasticity and handiness of the buccal mucosa is superior to the penile skin promoting the use of graft in an original fashion.
| Conclusion|| |
It is important to remember that all urethroplasty procedures, despite a meticulous technique, have the potential to fail and that any substitution material has the potential to deteriorate with time. Further studies into the basic mechanism of urethral wound healing and spongiofibrosis are strongly suggested to clarify the etiology of the recurrences.
It is widely recognized that reconstructive urethral surgery requires technical refinements. Fibrin glue represents a slight but meaningful device to perfect surgical technique of bulbar urethral reconstruction.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]