|Year : 2020 | Volume
| Issue : 5 | Page : 206-210
Dorsolateral onlay buccal mucosal urethroplasty for anterior urethral strictures by unilateral urethral mobilization: A prospective study
P Puvai Murugan, A Bhalaguru Iyyan, Akash Selvathangam
Department of Urology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
|Date of Submission||18-May-2020|
|Date of Decision||14-Jun-2020|
|Date of Acceptance||08-Aug-2020|
|Date of Web Publication||27-Oct-2020|
A Bhalaguru Iyyan
Department of Urology, PSG Institute of Medical Sciences and Research, Coimbatore - 641 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Purpose: Complete urethral mobilization may endanger the lateral vascularity of the urethra in buccal mucosal graft (BMG) urethroplasty in stricture urethral disease. The present study aimed to evaluate the outcomes of BMG urethroplasty by dorsolateral onlay technique in patients with anterior urethral stricture. Materials and Methods: This was a prospective interventional study conducted at the Department of Urology at PSG Institute of Medical Sciences and Research between January 2015 and December 2018. Patients diagnosed with anterior urethral stricture who underwent dorsolateral onlay urethroplasty were included in this study. Results were considered satisfactory with the Qmax between 8 mL/s and 15 mL/s. Failed outcome was defined as persistent lower urinary tract symptoms, stricture on retrograde urethrogram, Qmax <8 mL/s, and requiring repeated urethra intervention. Results: A total of 54 patients underwent BMG urethroplasty by dorsolateral onlay graft with a mean age of 47.6 years. The patients with a range of stricture length 3–14 cm were included in this study. Short-term success rate (Qmax >15 mL/s) was achieved in 42 patients, while satisfactory results (Qmax 8–15 mL/s) were observed in nine patients and failure (Qmax <8 mL/s) occurred in three patients. Oral and perineal complications were treated conservatively with oral antibiotics and analgesia. None of the patients in this study had a postoperative perineal hematoma, graft infection, and scrotal swelling. Conclusion: Overall observations suggest that dorsolateral onlay BMG urethroplasty with unilateral urethral mobilization for an anterior urethral stricture is a feasible and effective option with favorable outcomes.
Keywords: Buccal mucosa, dorsolateral, unilateral mobilization, urethral stricture, urethroplasty
|How to cite this article:|
Murugan P P, Iyyan A B, Selvathangam A. Dorsolateral onlay buccal mucosal urethroplasty for anterior urethral strictures by unilateral urethral mobilization: A prospective study. Urol Sci 2020;31:206-10
|How to cite this URL:|
Murugan P P, Iyyan A B, Selvathangam A. Dorsolateral onlay buccal mucosal urethroplasty for anterior urethral strictures by unilateral urethral mobilization: A prospective study. Urol Sci [serial online] 2020 [cited 2020 Nov 28];31:206-10. Available from: https://www.e-urol-sci.com/text.asp?2020/31/5/206/299263
| Introduction|| |
Urethral stricture is a common urinary tract disorder, and the exact incidence in the Indian population is not known. One-third of patients had pananterior urethral strictures involving penile and bulbar urethra. Internal urethrotomy was the treatment of choice in these patients. The long-term results of internal urethrotomy are poor, requiring either repeated dilatation or repeated endoscopic urethrotomy. The traditional approach for the management of anterior urethral stricture is a two-stage Johanson repair along with the use of free grafts; for example, prepuceal skin, buccal mucosa, tunica vaginalis, lingual mucosa, posterior auricular skin, bladder mucosa, and intestinal mucosa were used if required. Barbagli described dorsal onlay free graft urethroplasty, while Asopa reported ventral sagittal urethrotomy with inlay patch. Various modifications including dorsal inlay, dorsolateral, and ventral onlay graft urethroplasty using different grafts including full-thickness skin graft and mucosal graft have been proposed in recent years. However, the choice of the treatment is dependent on the patient's condition and the surgeon's preference.
The use of a buccal mucosa graft (BMG) was first introduced by Humby in 1941 for urethral reconstruction evaluating better outcomes of anterior urethroplasty. There is controversy as to whether BMG should be placed dorsally or ventrally. In the penile urethra, most surgeons placed it dorsally, where the success rate ranged between 85% and 100%.,,, In the bulbar urethra, as per the clinical situation, many experts placed it ventrally, or they combined ventral, dorsal, and even lateral placements. Previous studies have reported a similar success rate ranging 84%–100% for both dorsal and ventral graft placement with good blood supply and mechanical support.,,, In 2000, Kulkarni et al. described the one-sided urethral mobilization to place a dorsolateral buccal graft over the stricture site. Many studies have been published in the literature evaluating the outcomes and feasibility of BMG urethroplasty with a unilateral approach., Despite several available studies in the literature, this study will add evidence to the literature. The present study aimed to evaluate the outcomes of BMG urethroplasty by dorsolateral onlay technique in patients with anterior urethral stricture.
| Patients and Methods|| |
This was a prospective interventional study conducted at the Department of Urology at PSG Institute of Medical Sciences and Research between January 2015 and December 2018. Patients diagnosed with anterior urethral stricture either short segmented (<3 cm) or long segmented (>3 cm) on retrograde urethrogram (RGU) who underwent dorsolateral onlay urethroplasty were included in this study.
Patients with a previous history of urethroplasty, hypospadias, urethral fistula, perineal infection, periurethral fistula, and recurrent urethral instrumentation were excluded from this study. The study protocol was approved by the Institutional Review Board and Hospital Ethics Committee (Approval No.: 17/396), and the study was in accordance with the Declaration of Helsinki. Written informed consent was obtained from each patient before enrollment.
Each patient was evaluated using detailed preoperative data including local examination and urine culture. All patients received broad-spectrum antibiotics 12 h before surgery. Chlorhexidine mouthwash and betadine perineal wash were prescribed every 3 h on the previous day of surgery. The procedure was done under general anesthesia with nasal endotracheal intubation. In lithotomy position, cystourethroscopy was performed to evaluate the length of the stricture and that of the normal urethra. Approximate length of the BMG was harvested from the cheek (from one or both sides). The raw area of the cheek was approximated using 3-0 chromic catgut with continuous suturing. The buccal fat was defatted and placed in normal saline. A mid-perineal incision was made; ischiocavernosus and bulbospongiosus muscles were incised and separated. Turner-Warwick ring retractor was placed. The ventral aspect of the urethra was dissected from 3 o'clock to 9 o'clock position [Figure 1]a. The dorsal semicircle of the urethra was left undissected to preserve the vascularity. The length of the dissection extended from the bulbomembranous junction to the external urethral meatus depending on the stricture length. Urethrotomy was made in the midline dorsally. The approximate length of the defatted BMG was sutured to the open urethral plate using 4-0 Vicryl with continuous sutures [Figure 1]b. At the proximal and distal end, few interrupted sutures were taken and fixed to the corporal margin. Quilting sutures were applied to keep the graft as opposed to the tunica; 16 Fr Foley's catheter was inserted into the bladder [Figure 1]c and [Figure 1]d. Minivac drain was placed adjacent to the graft site. The bulbospongiosus muscle was approximated in the midline [Figure 1]e. Subcutaneous tissue and skin were closed, interrupting absorbable sutures.
|Figure 1: Surgical procedure: (a) the ventral aspect of the urethra; (b) open urethral plate using 4-0 Vicryl with continuous suturing; (c) insertion of 16 Fr Foley's catheter; (d) application of quilting sutures; (e) the bulbospongiosus muscle being approximated in the midline|
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Cold oral liquids were started 4 h postoperatively in the first 48 h; after that, chlorhexidine mouthwash was advised every 3 h. Oral broad-spectrum antibiotics were continued until the catheter was removed. The patients ambulated on the 2nd postoperative day, and the drain was removed when the collection was <10 mL over 48 h. The patients were discharged from the hospital 5–7 days postoperatively. Foley's catheter was removed 3 weeks after surgery. RGU and uroflowmetry were done at 3, 6, and 12 months postoperatively and yearly thereafter.
A successful outcome was defined as normal voiding, no stricture on RGU, Qmax >15 mL/s, and no subsequent instrumentation needed. Results were considered satisfactory with the Qmax between 8 mL/s and 15 mL/s. Failed outcome was defined as persistent lower urinary tract symptoms, stricture on RGU, Qmax <8 mL/s, and requiring repeated urethra intervention.
Categorical variables were presented in number and percentage and continuous variables were presented as mean (range).
| Results|| |
A total of 54 patients who underwent BMG urethroplasty by dorsolateral onlay graft were included in this study. The mean age of the patients was 54.16 years (range, 22–74 years). The mean duration of the symptoms was 16 months (range, 3–28 months). The mean length of the strictures was 9 cm (range, 3–14 cm). The mean operative time was 130 min ranging from 90 to 180 min. The mean hospital stay was 10 days. Etiologies of the anterior urethral strictures are listed in [Table 1].
The stricture location in the majority of patients (n = 29) was penobulbar. The most common presentation was difficulty in passing urine and painful micturition which occurred in 88% of the patients. Acute urine retention was seen in 8% of the patients. The mean preoperative Qmax was 6.20 mL/s, and the mean postoperative Qmax at 3, 6, and 12 months was 16.09, 21.54, and 21.48 mL/s, respectively.
Successful treatment was achieved in 42 patients, while satisfactory results were observed in nine patients and failure occurred in three patients. Among the patients with successful outcomes (Qmax >15 mL/s), six of them had bulbar panurethral stricture, 13 had a penile urethral stricture, and 23 had panurethral stricture postoperatively. Among nine patients with satisfactory outcomes (Qmax 8–15 mL/s), two, three, and four patients had bulbar panurethral, penile, and panurethral strictures, respectively. In the three patients where the failure occurred, there were no patients with bulbar panurethral stricture; however, one patient had a penile urethral stricture and two patients had panurethral stricture [Table 2]. The postoperative RGU was found to be normal in 46, 52, and 53 patients during 3-, 6-, and 12-month follow-up, respectively, while the rest of the patients showed strictures on postoperative follow-ups [Table 3].
Oral cavity bleeding, facial pain and swelling, restriction of mouth opening, and oral numbness were observed in nine patients. Eight patients had urethral stricture recurrence, and superficial wound infection and meatal stenosis were present in two patients each. Oral and perineal complications were treated conservatively with oral antibiotics and analgesia. Discharges from the wound were sent for culture and treated according to the sensitivity report. None of the patients in this study had a postoperative perineal hematoma, graft infection, and scrotal swelling [Table 4].
| Discussion|| |
Management of pananterior urethral strictures was challenging to the modern urologists and is still difficult in the field of reconstructive urethral surgery. Internal urethrotomy and urethral dilation were commonly used procedures, but the failure rates are high with more recurrence rate and many patients were subjected to surgical repair.
Lichen sclerosis is one of the causes of urethral stricture disease which may involve the fossa navicularis, pendulous urethra, and bulbar urethra and can result in a panurethral stricture, for which prepuceal skin urethroplasty or buccal mucosal urethroplasty is one of the treatment options.
The present study included 54 patients who underwent BMG urethroplasty by dorsolateral onlay graft to manage urethral stricture. The key findings suggest that idiopathic disease was the most common cause of stricture, followed by instrumentation. Buccal mucosal donor site heals with almost no complications and no graft loss occurred. This is in accordance with the previous studies conducted in patients with long anterior urethral strictures using dorsolateral buccal mucosal urethroplasty.,,,
In 1996, Barbagli et al. performed dorsal onlay graft using buccal mucosal urethroplasty. They reported that prepuceal skin graft urethroplasty is associated with higher failure rates than buccal mucosal urethroplasty.
According to the previous study, distal bulbar urethral stricture can be managed by dorsal onlay graft, while ventral onlay is preferred for the proximal part of the urethra. Patients who underwent urethroplasty with long anterior urethral strictures showed compromised vascular supply due to extensive spongioflbrosis. Later on, Barbagli et al. found a similar success rate and stricture recurrence rate between patients who underwent ventral, dorsal, and lateral onlay procedures in the placement of the mucosal graft. Kulkarni et al. have reported good outcomes of 83% with dorsal onlay technique through the dorsolateral mobilization of the urethra. The buccal mucosa is readily available from all patients and is easily harvested from the inner cheek or lower lip, providing the advantage of a concealed donor site scar.
The advantages of BMG are as follows: buccal mucosa is easy to harvest and easy to handle surgically; it has no hair with thick elastic rich epithelium, making it tough; it is compatible in a wet environment; it has early ingrowth; it has high vascular lamina propria, which facilitates inosculation and imbibitions. Dorsal onlay BMG urethroplasty by unilateral urethral mobilization is the procedure of choice in the management of anterior urethral strictures and has improved outcomes in this study. Circumferential mobilization of the urethra is one of the drawbacks in the previously reported conventional dorsal onlay urethroplasty. To overcome this, a novel method was proposed recently. In 2009, Singh et al. reported the feasibility of dorsolateral onlay urethroplasty in 17 patients with long or multiple strictures of the anterior urethra. A case study of a 22-year-old male who underwent dorsolateral onlay urethroplasty for pananterior urethral stricture by unilateral mobilization approach resulted in good voiding with a satisfactory flow rate with no urinary complaints. Thus, preserving vascular supply on one side minimizes the chances of developing ischemia and chordee. Similar results were obtained by a previous hospital-based prospective interventional study. Prabha et al., in 2016, published a study of 20 patients with urethral strictures where BMG urethroplasty was done using a perineal route with a success rate of 85%. This was a single-stage procedure which was reported to be a good, safe, and minimally invasive treatment for the management of long urethral stricture. In the present study, treatment was successfully done in 42 patients and satisfactory results were obtained in 9 patients. Therefore, the success rate with a follow-up of 12 months was 94%. This was in agreement with the previously reported success rate in the range of 85%–94%.,, However, the Barbagli procedure showed success rates of 99% and 66% in short- and long-term outcomes, respectively, for the circumferential mobilization of the urethra with a dorsal onlay patch. Complications in this study were comparable with other studies.,, Furthermore, the present study did not find a postoperative chordee. Previously published data of 30 patients with long-segmented anterior urethral strictures treated by a dorsolateral free buccal mucosa graft reported chordee in one patient.
This study is limited by a small number of patients with short follow-up time up to 12 months.
| Conclusion|| |
The dorsolateral onlay BMG by unilateral urethral mobilization is a safe and feasible form of graft placement with a reduced chance of graft rejection and postoperative complications for anterior urethral strictures. BMG is an ideal substitute for the urethra in treating anterior urethral stricture with minimal donor site morbidity.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kulkarni S, Kulkarni J, Surana S, Joshi PM. Management of panurethral stricture. Urol Clin North Am 2017;44:67-75.
Dubey D. The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures. Indian J Urol 2011;27:392-6.
] [Full text]
Mundy AR. Re: Reconstruction of the male urethra in strictures. Eur Urol 2007;51:1139.
Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty. J Urol 1996;155:123-6.
Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology 2001;58:657-9.
Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol 2011;59:797-814.
Humby G. A one-stage operation for hypospadias repair. Br J Surg 1941;29:84-92.
Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol 1998;160:1307-9.
Barbagli G, Selli C, di Cello V, Mottola A. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. Br J Urol 1996;78:929-32.
Dubey D, Kumar A, Bansal P, Srivastava A, Kapoor R, Mandhani A, et al
. Substitution urethroplasty for anterior urethral strictures: A critical appraisal of various techniques. BJU Int 2003;91:215-8.
Iselin CE, Webster GD. Dorsal onlay urethroplasty for urethral stricture repair. World J Urol 1998;16:181-5.
Barbagli G. When and how to use buccal mucosa grafts in penile and bulbar urethroplasty. Minerva Urol Nefrol 2004;56:189-203.
Elliott SP, Metro MJ, McAninch JW. Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754-7.
Heinke T, Gerharz EW, Bonfig R, Riedmiller H. Ventral onlay urethroplasty using buccal mucosa for complex stricture repair. Urology 2003;61:1004-7.
Kane CJ, Tarman GJ, Summerton DJ, Buchmann CE, Ward JF, O'Reilly KJ, et al
. Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction. J Urol 2002;167:1314-7.
Kellner DS, Fracchia JA, Armenakas NA. Ventral onlay buccal mucosal grafts for anterior urethral strictures: Long-term followup. J Urol 2004;171:726-9.
Singh BP, Pathak HR, Andankar MG. Dorsolateral onlay urethroplasty for anterior urethral strictures by a unilateral urethral mobilization approach. Indian J Urol 2009;25:211-4.
] [Full text]
Prabha V, Devaraju S, Vernekar R, Hiremath M. Single stage: Dorsolateral onlay buccal mucosal urethroplasty for long anterior urethral strictures using perineal route. Int Braz J Urol 2016;42:564-70.
Habib AK, Alam AK, Amanullah AT, Rahman H, Hossain AK, Salam MA, et al
. Dorsolateral onlay urethroplasty for long segment anterior urethral stricture: Outcome of a new technique. Bangladesh Med Res Counc Bull 2011;37:78-82.
Chaudhary R, Jain N, Singh K, Bisoniya HS, Chaudhary R, Biswas R. Dorsolateral onlay urethroplasty for pan anterior urethral stricture by a unilateral urethral mobilisation approach. BMJ Case Rep 2011;2011. doi:10.1136/bcr.10.2010.3409.
Kulkarni SB, Barbagli G. Nasim S. In the Book, Art of Urethral Reconstruction. Surgical reconstruction of bulbar urethra. Gurgaon: Elsevier; 2012. p. 45.
Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M. Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: Are results affected by the surgical technique? J Urol 2005;174:955-7.
Kulkarni SB, Joshi PM, Venkatesan K. Management of panurethral stricture disease in India. J Urol 2012;188:824-30.
Barbagli G, Morgia G, Lazzeri M. Dorsal onlay skin graft bulbar urethroplasty: Long-term follow-up. Eur Urol 2008;53:628-33.
[Table 1], [Table 2], [Table 3], [Table 4]