Year : 2003 | Volume
: 19 | Issue : 2 | Page : 152--156
Buccal mucosal dorsal substitution urethroplasty in recurrent anterior urethral stricture
Shailesh A Shah, Prakash Ranka, Rajesh Choudhary, Manish Dhawan, Manish Vishnagara
Department of Urology and Kidney Transplantation, Institute of Kidney Diseases and Transplantation Sciences, Ahmedabad, India
Shailesh A Shah
Kidneyline Healthcare, 1st Floor, Harikrupa Towers, Near Govt. Ladies Hostel, B/h. Gujarat College, Ellisbridge, Ahmedabad - 380 006
Objective: To evaluate the durability of dorsal free graft aurethroplasty using buccal mucosa in adult recurrent bulbar and pendulous urethral strictures.
Patients and Methods: We treated 40 patients with recurrent bulbar and penile urethral strictures during a period of 4 years. Mean age was 40 years. All patients underwent single stage urethral reconstruction using nontubularized dorsal onlay buccal mucosa graft. The length of stricture dealt with was in the range of 2.5 cm to 12 cm. Follow-up was done at 3 weeks, 3 months, 6 months and then yearhv by uroflowmetry and if required by retrograde urethrogram.
Results: Outcome was favourable in 38 patients (95%). 1 patient (2.5%) required VIU. I patient (2.5%) died due to pulmonary embolism in immediate postoperative period.
Conclusions: Buccal mucosa is easy to harvest. It has thin and well- vascularized lamina propria with efficient imbibitions. Free graft placed dorsally over the tunica gains the mechanical support of the corpora and obviates urethrocele or diverticula formation. The technique offers the advantages of a fixed well-vascu larized surface with improved graft neo-vasculari-ation, reduced graft shrinkage, and optimum durability of graft.
|How to cite this article:|
Shah SA, Ranka P, Choudhary R, Dhawan M, Vishnagara M. Buccal mucosal dorsal substitution urethroplasty in recurrent anterior urethral stricture.Indian J Urol 2003;19:152-156
|How to cite this URL:|
Shah SA, Ranka P, Choudhary R, Dhawan M, Vishnagara M. Buccal mucosal dorsal substitution urethroplasty in recurrent anterior urethral stricture. Indian J Urol [serial online] 2003 [cited 2021 Jul 30 ];19:152-156
Available from: https://www.indianjurol.com/text.asp?2003/19/2/152/37148
Substitution urethroplasty by ventral onlay of a full thickness penile skin graft has been a mainstay in the repertoire of urethroplasty since it was first reported by Presman and Greenfield in 1953.  Applied ventrally over the incised urethra, the graft often lacked the mechanical support of a fixed bed, which allowed it to fold on itself. Long-term follow-up revealed that ventrally placed grafts are prone to shrinkage and a reason for late failure. , Less commonly urethral sacculation at the graft site would occur with its attendant problem of sequestration of urine and semen.  Based on the dorsal approach to stricture disease described by Monseur (1980),  Barbagli et al (1996)  proposed dorsal rather than ventral application of graft. This technique allows the graft to be spread and anchored onto the under surface of the corporeal bodies overlying the dorsally incised stricture offering a more secure bed and improving the chances of neovascularization.
Penile foreskin is an ideal substitute for urethral reconstruction in patients with urethral stricture disease or hypospadias. However, when local tissue is unavailable because of circumcision, Balanitis xerotica obliterans or scar tissue, extra-genital skin or mucosa is used as an alternative donor site (Webster, 1984).  Recently, buccal mucosa has been suggested for urethral reconstruction in patients with complex hypospadias and men with bulbar urethral strictures (Baskin and Duckett, 1995),  (Wessels and McAninch, 1996).  We report our experience of dorsal onlay graft urethroplasty using buccal mucosa in 40 patients with recurrent anterior urethral stricture.
Patients and Methods
From March 1996 to March 2000, 40 patients were treated by dorsal substitution urethroplasty using buccal mucosa in bulbar and penile urethra. The underlying etiology was inflammatory (25%), post traumatic (37%), iatrogenic (30%) and balanitis xerotica obliterans (8%). Out of 40 patients, 28 patients had previously undergone repeated VIU [Figure 1]A. 9 patients had undergone end to end urethroplasty, 3 patients had stricture with BXO with h/o previous dilatations. Age of patients was in the range of 22 years to 58 years (mean age = 40 years). Length of stricture treated was 2.5 cm to 5 cm (in 17 patients). 5 cm to 7.5 cm (in 12 patients), 7.5 to 10 cm (in 8 patients) and 10 cmn to 12 cm (in 3 patients) [Figure 2]A.
The operative procedure usually involved 2-team approach. The urethra was complexly mobilized from the corpora cavernosa and rotated 180° and the strictured area was incised dorsally at 12 o' clock position. Stricturotomy was continued for 1.5 to 2 cm into the healthy urethra proximal and distal to the stricture. The inner cheek was the preferred donor site in the area just below the Stenson's duct. The graft was defatted and tailored in individual case [Figure 3].
A buccal mucosa graft of about 2.5 cm width and adequate length was harvested. The graft was spread and fixed to the overlying corporeal bodies by interrupted sutures with tunica albuginea. The left mucosal margin of the opened urethra was sutured to the left side of the patch graft. The urethra was rotated back to its original position and the right urethral margin was sutured to the right side of the patch graft after inserting a 16 F Foley catheter.
For an obliterative stricture. the urethra was transected at the stricture site and the graft was sutured to the tunica albuginea and proximal urethral edge [Figure 4]. The mobilized dorsal urethra was widely opened along its dorsal surface and rotated back over the patch graft and sutured to it, leaving an indwelling 16 F Foley catheter [Figure 5].
Pericatheter study was performed 3 weeks after surgery, followed by catheter removal if there was no extravasation [Figure 2]B. Regular follow-up included clinical evaluation and uroflowmetry at 3,6,12 and 18 months and thereafter when needed. Retrograde urethrogram and urethral calibration were performed only when peak flow rate was less than 14 ml/second.
The criterion adopted for successful urethral reconstruction: "No intervention required for a maximum period of one year".
Outcome was successful in 38 patients (95%). One patient (2.5%) required VIU 9 months following surgery. One patient (2.5%) died due to pulmonary embolism in immediate post-operative period. Wound infection was encountered in 3 patients (7.5%) in early postoperative period. Post-void dribbling or fistula was encountered in none. Follow-up was in the range of 2 years to 6 years (mean follow-up 4 years).
Postoperative retrograde urethrography performed 1.5 years after surgery in 1 patient shows a small inconsequential diverticulum [Figure 1]B. He is asymptomatic and voiding with a peak flow rate of 18 ml/sec.
The primary indications for substitution urethroplasty, using local skin flaps of free grafts, are recurrent or long strictures of bulbar urethra (>2 cm) and of penile urethra (>1 cm). Ventral onlay graft urethroplasty has been in vogue for several decades, but are prone to shrinkage, leading to recurrent stricture or diverticulum formation. The dorsal onlay graft procedure for bulbar strictures introduces some advantages over traditional ventral onlay graft urethroplasty (Wright and Webster, 1996).  The graft is fixed to the under surface of the corporeal bodies, which has an excellent blood supply and good mechanical support (Barbagli et al, 1996).  The spreading of the graft, making use of the tensile strength in the corporeal bodies, reduces the risk of graft shrinkage and chordee, while the dorsal graft bed avoids the problem of ventral sacculation, by interposing the graft between the urethra and corporeal bodies, fistula formation appears to be limited (Wright & Webster, 1996).  This technique is also useful for strictures previously operated as it allows repair on the contralateral side of the urethra and avoids the previously scarred area.
Venn and Mundy (1997)  reported their series of 39 patients, who underwent a 1-stage urethroplasty using buccal mucosa. They concluded that harvesting of buccal mucosa is quicker and easier, and avoids the potential morbidity of raising the penile skin flap, i.e., torsion deformity of the penis, and from circumcision or other penile scarring which is generally resented by patients. They have stopped preputial and penile skin flaps in favour of buccal mucosal free grafts as the material of choice.
Barbagli et al (1998)  preferentially used a preputial graft but when local epithelial tissue was unavailable, buccal mucosa was preferred to other types of extra-genital free grafts because of its qualities, i.e., thin, elastic and hairless. Furthermore, buccal mucosa is extremely resistant to infection as well as to skin disease such as balanitis xerotica obliterans (Andrich and Mundy, 2001). 
We have used buccal mucosa in all our patients. We have observed that patients seem increasingly concerned about the cosmetic aspects of the surgery. So buccal mucosa would appear to be the material of choice as it avoids additional penile scars, can be harvested quickly and easily and provides a logical option in patients with BXO.
In the present series, the dorsal onlay graft urethroplasty using buccal mucosa has a success rate of 95% at a median follow-up of 4 years. Iselin & Webster (1999)  in their series of 29 men who underwent dorsal onlay graft urethroplasty reported a high early success rate of 97% at a median follow-up of 19 months. They, however, maintained that a long-term follow-up is mandatory as the success of urethroplasty is measured in decades. At 10 years, a 40% re-stricture rate with substitution repairs using pedicled inlays has been reported by Mundy (1995). 
Barbagli et al (1998)  reported dorsal onlay graft urethroplasty using penile skin in 31 patients and buccal mucosa in 6 patients. Their success rate was 90.3% with preputial grafts at a mean follow-up of 21.5 months while all the 6 buccal mucosal grafts were successful with mean follow-up of 13.5 months.
In a series of 70 patients who underwent anterior urethroplasty, Greenwell et al (1999)  concluded that for a circumferential repair of the urethra, particularly the penile urethra, a 2-stage repair using a free graft gives better result than a 1-stage repair using a flap or tube graft. But the 1 and 3-year re-stricture rates of the 2-stage reconstructions were the same as for patch grafts in their series.
Recently Asopa Hari S. (2001)  reported dorsal free graft urethroplasty for urethral strictures by ventral sagittal urethrotomy approach. He described a technique of laying open the stricture ventrally and then incising the urethra dorsally without mobilizing it to expose the tunica albuginea for the free skin or buccal mucosa graft followed by retubularization of the urethra in 1 stage.
The technique used in the present series was the same as described by Barbagli et al (1996).  We conclude that the innovation of dorsal substitution urethroplasty with buccal mucosal free grafts may prove to be a promising approach in ensuring a successful outcome in the treatment of anterior urethral strictures. However, prolonged follow-up (minimum 5 years) is required for a satisfactory long-term evaluaton.
|1||Pressman D. Greenfield DL. Reconstruction of the perineal urethra with a free full-thickness skin graft from the prepuce. J Urol 1953; 69: 677.|
|2||Devine PC, Sakati LA, Poutasse FF, Devine CJ Jr. One stage urethroplasty: repair of urethral strictures with a free full thickness patch of skin. J Urol 1968: 99: 191.|
|3||Blum JA, Feeney MJ. Howe GE, Steel JF. Skin patch urethroplasty: 5-year follow-up. J Urol 1982; 127: 909.|
|4||Brigman JA, Deture FA. Giant urethral diverticulum after free fullthickness skin graft urethroplasty. J d'urol 1979: 121: 523.|
|5||Monsieur JL. Elargissement de P'uretre au moyen due plan susuretral, Bilan apres 13 ans sur 219 cas. J d'Urol 1980; 86: 439.|
|6||Barbagli G, Selli C. Tosto A. Palminteri F. Dorsal free graft urethroplasty. J Urol 1996: 155: 123.|
|7||Webster GD, Brown MW, Koefoot RJ Jr, Sihelnick S. Sub-optimal results in full thickness graft urethroplasty using exterpenile skin donor site. J Urol 1984; 131: 1082.|
|8||Baskin LS, Duckett JW. Buccal mucosa grafts in hypospadias surgery. Br J Urol 1995; 76: 23.|
|9||Wessels H, McAnineh JW. Use of free grafts in urethral stricture reconstruction. J Urol 1996; 155: 1912.|
|10||Wright EJ, Webster GD. Dorsal graft repair urethral strictures. AUA News 1996; 1: 4.|
|11||Venn SN, Mundy AR. Early experience with the use of buccal mucosa for substitution urethroplasty. Br J Urol 1998; 81: 738-40.|
|12||Barbagli G, Palminteri F, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol 1998; 160: 1307-1309.|
|13||Andrich DE, Mundy AR. Substitution urethroplasty with buccal mucosal-free graft. J Urol 2001; 165: 1131-1134.|
|14||Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture. J Urol 1999; 161: 815-818.|
|15||Mundy AR. The long-term results of skin inlay urethroplasty. Br J Urol 1995; 75: 59.|
|16||Greenwell J, Venn SN, Mundy AR. Changing practice in anterior urethroplasty. Br J Urol 1999; 83: 631-635.|
|17||Asopa Hari S. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology 2001; 58: 657-659.|