Posteriorly Augmented Anastomotic Ureteroplasty with Lingual Mucosal Onlay Grafts: 8-year Multi-institutional Experience in 61 Cases

Lingual Mucosal Graft Ureteroplasty for Long Proximal Ureteral Stricture: 6 Years of Experience with 41 Cases

Objective To compare the outcomes of buccal versus lingual mucosal grafting for multiple failed hypospadias of children. Methods We have collected 62 children receiving buccal or lingual mucosal grafts from 2012 to 2015. The age range was 3.5-11 years. All cases of multiple failed hypospadias were operated for 2-4 times. All of them were redone with one-stage operation. Thirty-three cases received lingual mucosa graft. The mean age was (7.5±0.2) (3.5-11) years and mean operative frequency (2.8±0.7) (2-4) times. The area of grafts: width: 0.5-1 cm, length: 2-5 cm. The mean follow-up period was 1.3 (5/12-2) years. And 25 patients received lingual mucosal graft and 23 buccal lingual mucosal graft. The mean area of grafts: mean width: (1.2±0.21) (0.5-1.5) cm, mean length: (5.1±0.22) (2-6) cm. The mean follow-up period was (8.3±1.3) (5/12-1) years. Further 29 cases received buccal mucosa graft. The mean age was (7.0±0.5) (4-9.2) years and mean operative frequency (2.5±0.2) (2-4) times. The area of grafts: mean width: (1.0±0.11) (0.5-1.5) cm, mean length: (4.5±0.14) (2-5.3) cm. The mean follow-up period was (5-12) months. And 25 patients received lingual mucosal graft while 23 buccal lingual mucosal graft. The mean area of grafts: mean width: (1.2±0.21) (0.5-1.5) cm, mean length: (5.1±0.22) (2-6) cm. The mean follow-up period was (7.6±0.7)(5-12) years. The results were tested by SPSS 18.0. Rates of complications were compared by chi-square and t tests. Results There were no significant inter-group differences in age, preoperative times, length and width of grafts. No significant inter-group differences existed. Lingual mucosal graft group: fistula: 2/29(6.8%), stricture: 1/33(3.0%) and ventral curcature: 2/33(6.0%). Complications: 5/29(17.0%), successful rate: 24/29(83.0%), Hose score: 14.28±0.12; buccal mucosal graft group: fistula: 2/29(6.8%), stricture: 2/29(6.8%) and ventral curcature: 1/29(3.4%). Complication rate: 5/29(17.0%), successful rate: 24/29(83.0%), Hose score: 14.28±0.12. No inter-group differences existed in overall success, complication rate or Hose score. Conclusions Lingual and buccal mucosal grafts have achieved excellent outcomes. And lingual mucosal graft is superior to buccal mucosa graft so that it offers a viable option for multiple failed hypospadias in children. Key words: Hypospadias; Lingual mucous membrane; Oral mucosa

Objective: To share the technique of posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures as well as our initial experience with the technique. Methods: From October 2018 to September 2019, 10 cases of robotic and laparoscopic posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures were recruited from our database of Reconstruction of Urinary Tract: Technology, Epidemiology and Result (RECUTTER). The perioperative and follow-up data were recorded. Complete success was defined as the absence of clinical symptoms, relieved stenosis on imaging, and a stable estimated glomerular filtration rate without serious complications. Results: All surgeries were completed without serious complications. There were eight laparoscopic surgeries and two robotic surgeries. The median length of defect after posteriorly augmented anastomosis was 3 cm (range, 3-5 cm). The median length of the lingual mucosa graft was 4 cm (range, 3-5 cm). The median operative time was 237 minutes (range, 189-310 minutes). The median estimated blood loss was 40 mL (range, 10-100 mL). The median postoperative length of stay was 7.5 days (range, 5-22 days). The Double-J stent was removed median 3.5 months (range, 2-7 months) after the surgery. At the median follow-up of 11 months (range, 7-20 months), all patients achieved the successful criteria of treatment. Conclusion: The posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures is a feasible and safe technique, which may be an option especially for strictures marginally longer than those that can be safely repaired via end-to-end anastomosis.

Introduction: The surgical approach toward hypospadias repair in pre-pubertal boys with several unsuccessful surgeries is extremely difficult because of tissue loss and possibility of tissue complications. While buccal mucosa grafts (BMGs) remain the most widely used approach, there has been recent interest in lingual mucosa grafts (LMGs) which seem to offer potential benefits in terms of donor site morbidity and graft availability. At Khyber Teaching Hospital, Peshawar, this study assesses and compares BMG and LMG outcomes in inlay urethroplasty for complex hypospadias patients' cases. Methods: A retrospective analysis study of 62 pre-pubertal boys was done from July 2022 to July 2023. Patients had at least two failed hypospadias repairs. The patients’ records were reviewed and the study group was separated into BMG (n=29) and LMG (n=33) subgroups. Primary outcome measures were surgical success defined as a functional urethra after surgical intervention and complication rates for fistula, stricture, ventral curvature, aid, and peak flow during uroflowmetry. Cosmetic evaluation was performed with validated “How was it? (HOSE)” scores. Statistical was done with SPSS 18.0 for statistical chi square/t-tests and was considered significant if P value was <0.05. Results: Both groups had comparable complication rates (BMG: 83.0%, LMG: 84.8%) and success rates (BMG: 17.0%, LMG: 15.0%). There were no statistically relevant differences for fistula (6.8% and 6.0%), stricture (6.8% and 3.0%), or ventral curvature (3.4% and 6.0%) rates (p>0.05). The mean peak flow and HOSE score for patient’s (BMG: 14.28±1.03, LMG: 14.34±0.95) were comparable. Compared with BMG, LMG harvesting had less complications at the donor site. Conclusion: Both LMG and BMG deliver the same results for unsuccessful hypospadias repair in boys who have not reached puberty. However, LMG may be used when buccal tissue is not available, or there are unsuccessful attempts to harvest it. This adds to the literature suggesting LMG is a dependable method for advanced pediatric urethroplasty and increases the possibilities for repair in places with few resources. Keywords: Lingual mucosa, buccal mucosa, graft complications, hypospadias, urethroplasty.

Robotic-assisted Lingual Mucosal Graft Ureteroplasty for the Repair of Complex Ureteral Strictures: Technique Description and the Medium-term Outcome

Background: To compare buccal versus lingual mucosal grafts in substitution urethroplasty in terms of surgical outcome and donor site morbidity. Methods: A total of 50 patients who underwent single stage substitution urethroplasty for anterior urethral stricture from March 2008 to December 2014 were included in the study. Out of these 27 had buccal mucosal graft urethroplasty and 23 had lingual mucosal graft urethroplasty. The patients were compared for surgical outcome and donor site morbidity. Results: The mean age and stricture length were comparable in the two groups. The surgical outcome was also comparable in the two groups with 3 failures in buccal mucosal group and 2 in lingual mucosal group. Lingual mucosal graft was easier to harvest but overall donor site complications were comparable in both the groups. Conclusions: Lingual mucosal graft harvesting is easier and the surgical outcome is comparable to buccal mucosal grafts. The donor site morbidity is comparable to buccal mucosal grafts. Lingual mucosal grafts is especially useful in patients with sub mucosal fibrosis and unhealthy buccal mucosal.

ObjectiveThe purpose of this study was to compare the outcomes of the buccal mucosa and lingual mucosa used in children who received multiple failed hypospadias surgeries.MethodWe conducted a retrospective study of 62 children who received buccal or lingual mucosa graft urethroplasty in our hospital between 2012 and 2015. The ages ranged from 3.5–11 y. All cases included multiple failed hypospadias procedures, and the subjects received previous operations 2–3 times. All patients underwent one-stage operations. Thirty-three cases were treated with lingual mucosa grafts. The patient ages ranged from 3.5 to 11 y (median 7.5 y), and they had previous operations 2–3 times (mean 2.8±0.7). Grafts ranged from lengths of 2–6 cm (mean 5.1±0.46 cm) and widths of 0.5–1.5 cm (mean 1.2± 0.16 cm). Our follow-up was 5 to 12 m (mean 8.3±1.2 m). Twenty-nine cases were treated with buccal mucosa grafts. The patient ages ranged from 4 to 9.2 y (median 7.0 y), and they had previous operations 2–3 times (mean 2.5±0.2). Grafts ranged from lengths of 2–5.3 cm (mean 4.9± 0.28 cm) and widths of 0.5–1.5 cm (mean 1.0±0.11 cm). Our follow-up was 5 to 12 m (mean 7.9±0.5 m). The results were tested with SPSS 18.0. The rates of complications were compared by a chi-square test, and pre-operative conditions were compared by t test.ResultsFor the outcomes of the two groups, there was no significant difference between the groups in terms of age, preoperative surgery time, and the length and width of the grafts (p>0.05). For the lingual mucosa graft group, fistula: 2/33 (6.0%), stricture: 1/33(3.0%), ventral curvature: 2/33(6.0%), complications: 5/33(15.0%), success rate: 28/33(84.8%), Hose score: 14.34±0.95, peak flow: 6.5 ml/s-12.0 ml/s, and mean peak flow: 9.3±0.4 ml/s. For the buccal mucosa graft group, fistula: 2/29(6.8%), stricture: 2/29(6.8%), ventral curvature: 1/29 (3.4%), complication rate: 5/29(17.0%), success rate: 24/29 (83.0%), Hose score: 14.28±1.03, peak flow: 6.5 ml/s-12.0 ml/s, and mean peak flow: 9.2±0.2 ml/s. There were no differences between the two groups for overall success, complication rates, peak flow, and the Hose scores(P>0.05).ConclusionThe lingual mucosal graft and the buccal mucosa graft both achieved good outcomes, and the lingual mucosa graft made up for the shortcomings of the buccal mucosa graft, which provided a reliable way to treat the multiple failed hypospadias surgeries in pre-pubertal boys.

Intermediate-Term Outcomes and Complications of Long Segment Urethroplasty with Lingual Mucosa Grafts

86 LONG TERM RESULTS OF LINGUAL MUCOSAL GRAFTS FOR REPAIRING LONG ANTERIOR URETHRAL STRICTURES

Re: Outcome of 1-Stage Urethroplasty Using Oral Mucosal Grafts for the Treatment of Urethral Strictures Associated with Genital Lichen Sclerosus

Outcome of 1-Stage Urethroplasty Using Oral Mucosal Grafts for the Treatment of Urethral Strictures Associated With Genital Lichen Sclerosus

Long proximal or middle ureteral strictures remain challenging conditions. Although ileal replacement of the ureter or renal autotransplantation are possible solutions for these problems, both present complexities and considerable morbidity. In recent years, many urologists have tended to use oral mucosal grafts to repair complex proximal or middle ureteral strictures and thereby avoid ileal replacement and renal autotransplantation. A comprehensive search of oral mucosa graft ureteroplasty and lingual mucosa graft (LMG) ureteroplasty was performed. All literatures must be in English language. Most reports related to oral mucosa graft ureteroplasty focus on buccal mucosa grafts (BMGs). The available data about LMG ureteroplasty are limited. Both LMG and BMG are oral mucosa grafts that have similar histological structures. The success rates of urethroplasty with LMG and BMG are similar. Although there is still no comparative study between LMG and BMG for ureteroplasty, the limited reports show that LMG ureteroplasty is safe and effective for the management of ureteral strictures. This method provides one more option for the management of long proximal and/or middle ureteral strictures. However, the current studies on LMG ureteroplasty have a small sample size and are retrospective. More prospective, multicenter and large sample studies with long-term follow-up results that can further prove the efficacy of LMG ureteroplasty are still needed.

OBJECTIVE • This study was to evaluate donor-site complications of lingual mucosal graft harvesting for substitution urethroplasty. PATIENTS AND METHODS • 110 patients with anterior urethral strictures or hypospadias underwent lingual mucosal grafts (LMGs) urethroplasty. Dual LMGs were harvested from both sites separately or a long mucosal graft was harvested from one side to other side of tongue in 29 patients (group one); a shorter mucosal graft was harvested from one side of tongue in 81 patients (group two). A standard proforma (Appendix) was used for all patients. RESULTS • The mean follow up time was 22 months (range 6~41). At six months follow-up, numbness of tongue was reported in 19 patients (17.27%), parageusias in six (5.45%) and slurring of speech in 9 (8.18%). • Ninety-six patients were followed up for more than 12 mo. Numbness in operative area of tongue was documented in seven patients (7.29%), parageusias in three (3.13%) and slurred speech in three (3.13%). • None of these complications occurred in the six pediatric cases (<14 year) with a history of failed hypospadias repair. CONCLUSIONS • LMGs urethroplasty, as most patients, were satisfied, but there were certain complications that have not been previously described in the literature. • Most oral complications subsided gradually within the first year.

Objective To evaluate the outcomes of patients who underwent one–stage onlay or inlay urethroplasty using lingual mucosal grafts (LMG) to treat male patients with less available skin after a failed attempt at hypospadias repair. Methods We retrospective analyze the clinical material of 68 patients with failed hypospadias repairs were treated in our hospital between Jan. 2008 and Dec. 2013, The median age was 22 (4–45) years. The median prior unsuccessful repairs was 1.9 (1–6) times. Inclusion criteria were a history of failed hypospadias repair, insufficiency of the local skin that made a reoperation with skin flaps difficult, and necessity of another graft urethroplasty. Patients were excluded if they had undergone a failed hypospadias repair with a reoperative urethroplasty using the foreskin or a multistage repair urethroplasty. Two techniques of urethroplasty were performed according to the patients with or not penile curvature during the erection. One–stage onlay LMG urethroplasty was performed in 52 patients and a modified Snodgrass technique using one–stage inlay LMG urethroplasty was performed in 16. The median LMG urethroplasty length was 5.6 (4–13) cm. Results The median follow–up was 39 (5–70) mon, 54 patients voided well with urinary peak flow rates were median 24.5 (14.0 to 46.0) ml/s and complications developed in 14 patients (21.6%), including urethrocutaneous fistulas in 8 patients and neourethral strictures in 6 patients (meatal stenosis in 3 cases, proximal anastomotic site stricture in 3 cases). 8 patients with urethrocutaneous fistulas were repaired with salvage procedure, succeed in 4 and another 4 patients await further reoperation. Three patients with meatal stenosis were corrected by meatoplasty and 3 patients with proximal anastomotic site stenosis were only treated by dilatation for 4 and 6 months respectively, after that the patients voided well. Conclusions One stage onlay or inlay urethroplasty with LMG may be an effective option to treat the patients with less available skin after failed hypospadias repairs. Key words: Hypospadias; Failed; Urethroplasty; Lingual mucosa

Lingual Mucosal Graft Urethroplasty for Anterior Urethral Reconstruction