95 Critical review of a modified technique in buccal mucosa graft urethroplasty

Abstract

Introduction: This presentation will be discussing the modified technique used by the author in his repair of complex urethra strictures. Barbagli et al renewed interest in buccal mucosa (BM) onlaid graft urethroplasty in early 90's. He described the technique of dorsal onlaid graft to improve the revascularisation of the free graft, to prevent shrinkage of the graft, and minimised diverticulum formation. The technique has one major drawback, namely the dorsal onlaid graft is limited to mid and distal bulbar urethra only. The author modified this original technique by employing the BM graft as a ventral onlaid graft and successfully repaired over 126 urethral strictures extending from urethral meatus to proximal bulbar urethra over the period of 1996 to 2005.Result: Using this modified ventral onlaid BM graft, mobilisation of the urethra is not necessary. This preserves the integrity of the urethral blood supply. After the stricture is identified using the Lister sound, a ventral urethrotomy is carried out. The extend of the stricture and surrounding spongiofibrosis are carefully evaluated visually as well as re‐calibration of the distal and proximal extension of the stricturing process until normal urethra is identified. 1.5 cm wide graft is then harvested with variable length depending on the extend of the stricture. All donor sites are closed primarily. Finally, the graft is sutured in situ and surrounding spongiosum is re‐deployed to provide a vascular and supporting bed for the free graft. At the penile urethra, the dartos fascia is employed to provide support to the free graft. The length of the graft ranged from 2.5 to 15 cm. The stricture sites varied extending from urethra meatus to proximal bulbar urethra just below the external sphincter. 12% recurrent stricture was reported in this group after follow up longer than 15 months. All patients had cystoscopy at 3 and 15 months to evaluate their graft calibre and recurrent stricture rate. Two out of 126 patients required complete graft revision due to sclerosing of the entire graft secondary to recurrent UTI postoperatively. Recurrent stricture tends to occur at the junctional site of the graft and usually diagnosed at their first cystoscopy. Postmicturition dribbling, UTI, ejaculatory dysfunction, erectile dysfunction, stone formation and diverticulum formation is rarely reported when compared to pedicle penile skin graft urethroplasty or pedicle scrotal graft urethroplasty. No patients have reported donor site morbidity.Conclusion: The modified ventral onlaid BM graft has proven to be a reliable graft in dealing of complex urethral stricture.