Abstract
PurposeThe purpose of this review is to assess the potential role of tissue engineering for urethral reconstruction. It is well- recognised that urethrotomy remains the first-line therapy in the treatment of urethral stricture. Following on from the randomised study which recommended no difference between urethrotomy and urethral dilation, Steenkamp et al. reported long-term success rates of only 20%. Patients with longer strictures, penile or distal urethral strictures, and extensive periurethral spongiofibrosis typically do not respond well to repeated incisions. This report reviews the potential role of tissue engineering as applied to augmentation urethroplasty, which is the treatment of choice following failed urethrotomy.MethodsA review of the literature was carried out. The principal emphasis was on tissue engineering as applied to augmentation urethroplasty, but an introductory section reviews the use of urethrotomy and the background to contemporary practise with augmentation urethroplasty using oral mucosa.ResultsIt is evident that a cellular matrix which requires the ingrowth of cells is unlikely to be successful except for very short strictures. Other approaches such as injection of stem cells have not been adequately trialled in humans to date. Tissue-engineered substitute for autologous oral mucosa has been used and the results relating to this are reviewed.ConclusionsTissue engineering of autologous tissue for urethroplasty is expensive. It is unnecessary for the majority of cases, but could be potentially useful for very lengthy strictures, for instance, relating to lichen sclerosis. Whilst tissue-engineered oral mucosa has been successfully used, a great deal more work would be necessary to develop an appropriate matrix. Another study has looked at a larger series using an alternative tissue-engineered substitute, but the results have been very disappointing. At present, it has to be concluded that there is no effective and validated tissue engineering solution for the management of urethral stricture disease.
Highlights
Urethrotomy remains the first-line therapy in the treatment of a urethral stricture
Repeat internal urethrotomy offers no real chance of a cure after a third incision or if the stricture recurs within 3 months of the first incision
The intention of this paper is to review the potential for the use of tissue engineering in the management of urethral stricture disease
Summary
Urethrotomy remains the first-line therapy in the treatment of a urethral stricture. Following on from their randomised study which demonstrated no difference between urethrotomy and urethral dilatation, Steenkamp et al [1, 2] reported long-term success rates of only 20%. In patients with an unhealthy urethral bed (more than two prior operations), only two of six patients with a bladder matrix graft were successful, whereas all five patients with a buccal mucosa graft had a patent urethra At this time, whilst the results of these studies are of considerable interest, further information in terms of longer followup with objective assessment is essential before these data would lead to more widespread adoption of these techniques into routine clinical practice. A new bioengineered material was reported 3 years later, in an observational study of five boys with urethral defects of length 4–6 cm with a follow-up ranging from 36 to 76 months post-operatively, using polylactide-co-glycolide (PLGA), seeded with autologous bladder smooth muscle and urothelial cells, and prepared as tubularised grafts. There was no significant difference between the average success rates of the dorsal and the ventral onlay procedures, 88.4% and 88.8% at 42.2 and 34.4 months in 934 and 563 patients, respectively [40]
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