Bladder Mucosal Graft Research Articles

Different outcomes in urethral reconstruction using elastin and collagen patches and conduits in rabbits

To study the feasibility of urethral reconstruction with two urethroplasty techniques using an elastin and collagen heterograft in rabbits. Fifty-two male rabbits were studied. Two types of injury, (1) a 1.5 x 0.6 cm2 semicircumferential defect; (2) a 1.5 cm segmental defect of the penile urethra, were created and repaired using size-matched elastin and collagen patches or tubed conduits. Urethral repair by primary closure for the type 1 injury and a tubularized autologous bladder mucosal graft for the type 2 injury served as controls. At 3 months, urethral diameter was measured with retrograde urethrography. The animals were then euthanized for histological examination. The postoperative complication rate was significantly higher in the urethral reconstructions using tubed collagen (83%) and elastin (50%) grafts compared to the patch onlay grafts (p = 0.001 for collagen and p = 0.01 for elastin) and tubularized ABM (10%, p = 0.003 and 0.05, respectively). At the type 2 injury site, a dense circumferential fibrosis developed after all repairs. Only minimal ventral fibrosis presented in the type 1 injury repair. The intensity of chronic inflammation and fibrosis was greatest when collagen was used for the urethral repair. In the elastin urethral repairs the urethral diameter decreased significantly for the tubed repair compared to the patch onlay (p = 0.02). Urethral injury repair using elastin and collagen biomaterials is feasible in the rabbit model. The results of onlay urethroplasty using the elastin and collagen patches are significantly superior to those using the elastin and collagen tubed conduits.

The treatment of complex urethral stricture greater than 8 cm long

To evaluate the selection of different procedures and the feasibility for the treatment of long segment urethral stricture. Seventy-six patients with complex urethral stricture greater than 8 cm long underwent different procedures of urethroplasty. Of them various mucosa grafts urethral reconstruction were adopted in 42 cases (colonic mucosal graft, n = 26; buccal mucosal graft, n = 10; bladder mucosal graft, n = 6); One-stage pedicle flaps urethroplasty in 20; two-stage urethroplasty of Johanson procedure in 12; and penile urethra-prostatic urethra anastomosis, three-stage urethroplasty in 2. In early followed up (within 6 months postoperatively), 67 patients (88%) voided well and complications developed in 10. Among the 70 patients who lasted more than 1 year after operation, 51 cases were followed up. Forty-four patients voided well, and complications developed in 8. Of the 8 cases urethral restructure developed in 2 (18%) for pedicle flaps urethroplasty, 2 for colonic mucosal urethroplasty (9%), 1 for buccal mucosal graft (1/7), 1 for bladder mucosal graft (1/3); penile chordee in 2 (2/5), and one of them was accompanied by hair bearing neourethra for two-stage urethroplasty of Johanson procedure. Colonic mucosal and buccal mucosal grafts urethroplasty are feasible procedures for the treatment of long segment urethral stricture, and Colonic mucosal graft urethroplasty may be considered when more conventional procedures fail or complicated urethral strictures greater than 10 cm long.

MANAGEMENT AND OUTCOME OF COMPLEX HYPOSPADIAS REPAIRS

Repeated attempts at surgical repair of hypospadias may leave the penis scarred, hypovascular and shortened. We report on the clinical outcomes of our repaired complex hypospadias cases, often referred to as hypospadias cripples. We evaluated the records of 137 children and young adults from January 1980 through December 2002 who were referred to us after multiple unsuccessful hypospadias repairs. The records of 11 patients were inadequate. The ages of the remaining 126 patients ranged from 14 months to 35 years. The number of prior surgical procedures ranged from 2 to 23. Of the 126 cases 98 (78%) were repaired in a single stage (group 1) and 28 (22%) underwent multistage repairs (group 2). Major complications occurred in 17 cases (17%) in group 1 and in 2 (7%) in group 2. Major complications included repair breakdown, stricture, diverticulum and multiple fistulas. Minor complications occurred in 9 (9%) cases in group 1 and in 4 (14%) in group 2. Minor complications included a single small urethrocutaneous fistula, skin tethering, inclusion cysts and glandular irregularity. Urethral substitution using skin grafts and/or bladder mucosa resulted in a high complication rate of 32% and 37%, respectively, whereas use of buccal mucosa resulted in a 15% complication rate. Preoperative psychological counseling and discussion with other parents or patients were helpful. We no longer use free skin grafts and/or bladder mucosa for urethral substitution. Waterproofing the urethral tube was performed using either a dartos or tunica vaginalis flap. When the quality of the tissues was poor or severely scarred a 2-stage repair was performed. When resurfacing the penis local skin flaps may be insufficient or unreliable, and rotation of scrotal skin flaps or burial of the penis in the scrotum (Cecil-Culp) offers dependable skin coverage.

Management of urethral diverticulum complicating hypospadias repair

Background Urethral diverticula can occur after hypospadias repair, and may lead to stone formation, incomplete voiding, infection, postvoid dribbling, haematuria and other problems. We previously reviewed our experience with hypospadias complications. We separately analyzed those patients who developed urethral diverticula to attempt to identify predisposing factors and appropriate management strategies. Patients and methods We reviewed the available medical records and charts of 123 patients undergoing re-operation for hypospadias complications at The Children's Mercy Hospital from 1 May 1984 until 1 January 2003. Hypospadias cripples, traumatic fistulae, complications after circumcision and true intersex patients were excluded. Results Diverticula accounted for 11% of all complications (13 patients). The patients with diverticula were more likely to have perineal/proximal hypospadias. The initial repair was island tube urethroplasty in five, island onlay urethroplasty in seven and bladder mucosal graft in one child. The repair of the diverticulum in one stage was successful in 10 of the 13 patients. There was one recurrent diverticulum and two fistulas. A stricture was present in only one of the 13 patients but was detected overall in 14 of the 123 patients (11%). Conclusion Diverticula are uncommon after hypospadias repair, accounting for 11% of all complications in the present series. The stricture was not causative in 12 of 13 children. Repair of the diverticulum was successful after one attempt in 10 of 13 patients. The management of this complication is discussed.

Comparison of Angiogenic Activities after Urethral Reconstruction Using Free Grafts in Rabbits

Objective: To determine the most suitable type of graft-free penile skin grafts or mucosal grafts from bladder or buccal regions - for urethral reconstruction in an animal model, as evaluated on the basis of angiogenic activity. Methods: Twenty-two male White New Zealand rabbits were randomly divided into four groups. In the control group (group O, n = 4) a simple urethrotomy and closure was performed, whereas a ventral urethral defect was created in groups A, B, and C and then bridged using the following onlay patches: free penile skin (group A, n = 6), buccal mucosal graft (group B, n = 6), and bladder mucosal graft (group C, n = 6). On the 21st postoperative day, the animals were sacrificed and the retrieved implants were subjected to macroscopic and microscopic analysis. The angiogenic activity was assessed with immunohistochemistry, using the anti-CD31 MoAb and the phosphatase antialkaline phosphatase procedure. The native vascularity of penile skin as well as buccal and bladder mucosa was assessed in rabbits from group O ( n = 3). Statistical analysis was performed using the one-way ANOVA. Results: The angiogenesis in a magnification of ×200 in groups O, A, B, and C was 34.1 ± 4.1 (mean ± SD), 61.7 ± 6.4, 94.3 ± 6.4, and 91.5 ± 7.2 vessels per optical field, respectively. There were, statistically significant differences ( p < 0.001) between groups A and B and between groups A and C, but not ( p > 0.05) between groups B and C. The native vascularity of penile skin, buccal mucosa and bladder mucosa was 23.3 ± 3.0, 24.6 ± 3.7 and 17.0 ± 2.6 vessels per optical field, respectively. Conclusion: The viability of mucosal grafts from bladder or buccal regions is better than that of a free penile graft because of higher angiogenic activity. Although the mucosal grafts showed the same angiogenic activity, the buccal mucosa graft is preferable because of its easier harvesting.

Treatment of Urethral Defects: Skin, Buccal or Bladder Mucosa, Tube or Patch? An Experimental Study in Dogs

We studied 3 graft materials and 2 urethroplasty techniques in 24 adult male mongrel dogs. The animals were divided into 2 equal groups. In group 1 a 4 cm. segment of perineal urethra was excised and tubed urethroplasty was performed using free full-thickness skin, buccal and bladder mucosa grafts in 4 dogs each. In group 2 a 4 cm. urethral strip was excised and onlay urethroplasty was performed using the same graft materials in 4 dogs each. Retrograde urethrography was done and the animals were sacrificed at week 12. Autopsy specimens were calibrated with a 10Fr catheter. Hematoxylin and eosin stained sections were examined. Masson's trichrome stain was used to determine the extent of fibrosis. Urethral stricture was diagnosed by radiology and confirmed by calibration in 8 of the 12 dogs (66%) in group 1 but in only 1 of the 12 (8%) in group 2 (p <0.004). Buccal mucosa grafts were associated with the lowest stricture rate of 12%, followed by 37% for bladder mucosa and 62% for skin (p <0.2). There was no difference in neovascularization among the 3 grafts. Graft shrinkage was less than 10% for buccal mucosa compared with 20% to 40% for skin and bladder mucosa. The shrinkage rate was similar for the onlay and tube techniques. The intensity of chronic inflammation and fibrosis was highest in the skin grafts. Circumferential fibrosis was noted in association with tubed urethroplasty but not with the onlay technique. The theoretical advantages of buccal mucosal grafts were pathologically demonstrated. When possible, grafts should be used as an onlay rather than as a complete tube.

Uterocervicoplasty with a bladder mucosa layer for the treatment of complete cervical agenesis

Objective: To create an endocervical canal in a patient with a complete cervical agenesis. Design: Case report. Setting: University hospital. Patient(s): A 12-year-old girl presented with lower abdominal pain. On examination, complete vaginal agenesis was noted, with a 2-cm vaginal dimple. A pelvic magnetic resonance imaging scan disclosed an hematometra and absence of the cervix and vagina. Intervention(s): Initial surgical therapy consisted of a vaginoplasty with a sigmoid bowel segment and opening of the uterus by puncture and stenting. The cervical permeation failed, with immediate complete stenosis. A new attempt was made through a low sagittal hysterotomy by removing a central muscular cylinder and lining the channel with a free tubularized bladder mucosa graft. A stent was left in place. Main Outcome Measure(s): Hysteroscopy, hysterography, and clinical follow-up evaluation. Result(s): The cervical stent was removed after 5 months. A hysterography and hysteroscopy confirmed the permeability of the cervix, which was lined by a well-vascularized longitudinally folded mucosa. Regular menses had been noted for more than 3 years as of this report. Conclusion(s): Cervicoplasty with mucosal lining permits the creation of a patent cervical canal, even in the reputedly unfavorable forms of congenital cervical agenesis.

Free bladder mucosal autograft in the treatment of complicated vesicovaginal fistula.

To describe an effective and simple method for repairing complicated vesicovaginal fistula using a free bladder mucosal autograft. The study included 14 patients with an iatrogenic vesicovaginal fistula after hysterectomy or prolonged obstructed labour. An initial fistula repair had been attempted in 12 patients. All patients were then repaired using a free bladder mucosal graft technique 3-24 months (mean 8) after the fistula was diagnosed. Of the 14 patients 12 had an immediately successful result, with no evidence of leakage, but two required prolonged catheter drainage. Thirteen patients remained dry at the follow-up 3-15 months later. Two patients had stress urinary incontinence and three patients had urinary tract infection. The free bladder mucosal autograft technique is a simple, effective and fast method for vesicovaginal fistula repair. The technique produces an excellent repair of complicated vesicovaginal fistula, and appears to be more physiological and easier to perform than other transabdominal techniques.

Use of bladder mucosal graft for urethral reconstruction.

The ideal tissue for complex urethral reconstruction has yet to be determined, especially in patients with deficient preputium. The use of bladder mucosa as a free graft could be an alternative in these problem cases. Bladder mucosa graft urethroplasty was performed on 14 patients with penoscrotal or scrotal hypospadias. The mean age of the patients was 18.7 (range 14-23) years. Ten cases were subjected to primary urethral reconstruction while four cases had previous hypospadias repair. Complete urethral replacement by the bladder mucosa tube was performed in six patients. Meatal problems occurred in two (33.33%) patients and proximal fistula formed in one (16.67%) patient. A bladder mucosa graft was combined with preputial or tunica vaginalis grafts distally in eight cases, and one patient in the tunica vaginalis group developed fistula at the anastomosis of the bladder mucosa and tunica vaginalis grafts. The overall complication rate was 28.6%. Our initial results showed that bladder mucosa grafts can be used successfully for urethral reconstruction especially when combined with preputial or tunica vaginalis grafts distally.

LATE ONSET RECURRENT PENILE CHORDEE AFTER SUCCESSFUL CORRECTION AT HYPOSPADIAS REPAIR

Purpose Artificial erections are induced at hypospadias repair to prevent recurrent chordee. We describe the development and etiology of late onset recurrent chordee greater than 10 years after the initial surgery. Materials and Methods We reviewed the medical records of 22 patients with a median age of 4 years at surgery who were referred for evaluation of chordee 10 years after successful hypospadias repair. Results Of the 22 patients with recurrent chordee 13 had penoscrotal and 9 had proximal penile hypospadias at the initial operation. All originally required corporoplasty for the release of chordee, including Nesbit procedure in 19 and tunica vaginalis graft in 3. Successful artificial erections were induced after corporoplasty in all cases. Urethral reconstruction was performed with full-thickness preputial free grafts in 11 cases, bladder mucosal grafts in 7 and transverse island flap urethroplasty in 4. Although chordee developed during puberty (median age of onset 16 years, range 12 to 18), the median age at presentation for surgical correction was 21 years. Recurrent chordee was due to extensive fibrosis of the reconstructed urethra in 7 cases (32%), corporeal disproportion in 8 (36%) and both conditions in 7 (32%). Conclusions A successful artificial erection induced at hypospadias surgery does not prevent the delayed onset of recurrent chordee. Recurrent chordee may be secondary to the redevelopment of corporeal disproportion and/or extensive urethral fibrosis.

Late onset recurrent penile chordee after successful correction at hypospadias repair.

Artificial erections are induced at hypospadias repair to prevent recurrent chordee. We describe the development and etiology of late onset recurrent chordee greater than 10 years after the initial surgery. We reviewed the medical records of 22 patients with a median age of 4 years at surgery who were referred for evaluation of chordee 10 years after successful hypospadias repair. Of the 22 patients with recurrent chordee 13 had penoscrotal and 9 had proximal penile hypospadias at the initial operation. All originally required corporoplasty for the release of chordee, including Nesbit procedure in 19 and tunica vaginalis graft in 3. Successful artificial erections were induced after corporoplasty in all cases. Urethral reconstruction was performed with full-thickness preputial free grafts in 11 cases, bladder mucosal grafts in 7 and transverse island flap urethroplasty in 4. Although chordee developed during puberty (median age of onset 16 years, range 12 to 18), the median age at presentation for surgical correction was 21 years. Recurrent chordee was due to extensive fibrosis of the reconstructed urethra in 7 cases (32%), corporeal disproportion in 8 (36%) and both conditions in 7 (32%). A successful artificial erection induced at hypospadias surgery does not prevent the delayed onset of recurrent chordee. Recurrent chordee may be secondary to the redevelopment of corporeal disproportion and/or extensive urethral fibrosis.

Use of a free bladder mucosal graft for simple repair of vesicovaginal fistulae

The aim of this paper is to describe a simple, fast, and effective method for repair of difficult vesicovaginal fistulae by means of a free bladder mucosal graft. Six patients with high, large, multiple, or recurrent vesicovaginal fistulae were treated using a free bladder mucosal graft. Three patients underwent “early” repair (less than 3 months from time of injury) and 3 “late” repair (more than 6 months from time of injury). Via a suprapubic cystotomy, the mucosa of the fistulous tract was debrided without any attempt to excise the tract or close the bladder or vaginal defects. A free bladder mucosal graft was harvested from an unaffected portion of the bladder and placed over the fistulous tract, and mucosal approximation was made using interrupted 5-0 chromic stay sutures. The donor urothelial defect was allowed to re-epithelialize. A Foley catheter, suprapubic tube, and vaginal packing were left in place. Five patients noted an immediate result, with no evidence of leakage, and the suprapubic tube was removed by week 3. One patient required prolonged catheter drainage, and the tube was successfully removed by week 6. This patient had undergone irradiation. All patients remain dry at follow-up, which ranges from 2 to 6 years. We describe a simple and effective method for transabdominal vesicovaginal fistula repair, involving minimal mobilization, decreased dissection, and no need for rotational or interposition flaps, obviating the need to open the peritoneum. A free bladder mucosal graft can be used regardless of the individual anatomy or proximity to the ureteral orifices, because it can easily be tailored. This technique represents an important repair of difficult, recurrent, or multiple vesicovaginal fistulae.

Experience with Repair of Hypospadias Using Bladder Mucosa in Adolescents and Adults

From July 1984 to January 1994, 113 hypospadias operations were performed using a free bladder mucosa graft. There were 31 primary cases and 82 secondary cases in which prior operations had been done. The meatus was penile in 33 patients, penoscrotal in 72 and perineal in 8. The cosmetic and functional results were satisfactory. Postoperative complications included 8 fistulas that required closure and 6 cases of stenosis treated by dilation. Our results suggest that hypospadias repair with a bladder mucosa graft is feasible and reliable. The technique has been performed successfully in the most complex as well as simple cases in adults and adolescents.

Sutureless Rabbit Bladder Mucosa Patch Graft Urethroplasty Using Diode Laser And Solder

Fistula and strictures at the site of sutured anastomoses are frequent complications of major urethroplasty. We harvested bladder mucosa in 26 rabbits to repair large defects in the proximal urethra using laser-activated solder in the hope that such a repair would be stronger, faster to create and avoid common complications seen with conventional repair. Large oval defects were created in the proximal urethra in all animals undergoing urethroplasty. Twelve animals underwent bladder mucosa graft closure via diode (808 nm.) laser activation of an albumin-based solder (50 percent were suture-free). Fourteen additional animals underwent closure with 7-zero polydiaxanone suture (controls). Leak pressure and time of repair were recorded for each graft. Additional sections of bladder mucosa were harvested, transected and repaired by laser welding to determine tensile strength. In both groups, radiography, urethroscopy and clinical course were evaluated for as much as 6 weeks postoperatively. Urethroplasty time was significantly (p less than 0.01) shorter for the laser group (13.8 plus/minus 2.5 minutes) than for the sutured repair group (24.0 plus/minus 5.3 minutes). Initial leak pressures for the lasered grafts averaged at least 4 times those of sutured grafts (p less than 0.01). The tensile strength for lasered bladder mucosa was 3.16 plus/minus 1.12 kg./cm. 2 Early retrograde urethrograms (RUG) performed at 7 days (n = 5) revealed urinary extravasation and fistula formation in 2 control animals compared with a normal urethral appearance in 3 lasered repairs. Early retrograde urethrograms performed at 21 days (n = 21) demonstrated smooth-walled urethras with no evidence of fistula, stricture, or urinary extravasation in the lasered group; varying degrees of reactive mucosal proliferation were seen in the controls. Urethroscopy confirmed these observations. At 6 weeks, histologic examination confirmed the presence of viable graft in all animals. We conclude that bladder mucosa patch graft urethroplasty using diode laser welding and albumin-based solder is an attractive alternative to conventional methods.

Bladder Mucosal Grafts for Severe Hypospadias: A Successful Technique

Free grafts of bladder mucosa may be used to bridge long urethral defects in the repair of hypospadias. Strictures, which occur commonly at the proximal anastomotic site with the native meatus and where the bladder mucosa is exposed on the glans, have limited the use of the procedure. We have found that draining the proximal anastomosis prevents most strictures. When the distal most portion of the neourethra is formed from the skin of the ventral penile shaft and glans, no bladder mucosa is exposed and meatal stricture is thereby avoided.

A Rabbit Model of Free Bladder Mucosal Grafting in a Damaged Urethral Bed

Proximal and distal penile-urethral stomas were created in the rabbit and 1 to 3 months later a free bladder mucosal graft was placed in the damaged urethral bed. The graft adhered to a rapidly proliferating submucosa with active regeneration by post-transplantation day 5. All grafts were adherent and viable by days 10 to 14, during which time sham operated animals that had been stented only showed a degree of epithelial regeneration that was of variable quality and without submucosal proliferation. The graft may stimulate the subepithelial layer, and the most viable bladder mucosa may be associated with the most actively proliferating subepithelial layer, which is also the area of greatest neovascularity. Further studies may explain the apparent paradox of how a free bladder mucosal graft survives in a poorly vascularized, scarred urethral bed.

Grafting of Cultured Uroepithelium and Bladder Mucosa Into De-Epithelialized Segments of Colon in Rabbits

Urinary tract reconstruction using bowel can result in acid-base and electrolyte abnormalities. We tested the feasibility of grafting bladder mucosa and urothelial cells grown on a biodegradable polyglactin 910 scaffold onto de-epithelialized segments of bowel in the rabbit. A segment of de-epithelialized colon was either grafted with cultured urothelium on a collagen mesh scaffold (12 rabbits) or with free bladder mucosa (11 rabbits). In 10 rabbits that served as a control group another segment of bowel was isolated and de-epithelialized. No urothelial or bowel epithelial growth was present 4 weeks later in 10 of the isolated deepithelialized colonic segments grafted with the cultured urothelium. In 2 segments a minute focus of epithelium staining positively for anticytokeratin antibodies AE1 and AE3 was seen but this could not be histologically differentiated as either urothelium or native colonic epithelium. All 7 surviving animals that underwent a bladder mucosal graft had viable urothelium at sacrifice 30 days postoperatively. In 2 of the 7 rabbits microscopic nests of colonic epithelium were also found underneath the urothelial layer. Of the 7 internal controls 6 had no evidence of bowel epithelial regrowth 4 weeks after deepithelialization.This study demonstrated that a confluent layer of urothelial cells could be grown in culture using a scaffold of biodegradable mesh and rat tail collagen. We also showed that bladder mucosal grafts can be grown on de-epithelialized bowel segments. We were unable to graft successfully cultured urothelial cells onto a de-epithelialized bowel segment. Further improvement in understanding the role of the submucosal matrix in cell growth may lead to future success in covering large segments of de-epithelialized bowel with autologous urothelium.

Simplified postoperative management of hypospadias repair

Objective. To assess the effect of simplified postoperative management of hypospadias repair in an outpatient setting. Methods. The records of 162 boys were reviewed who underwent hypospadias repair by the following techniques: meatal-based flap (72), free skin graft (54), two-stage repair (21), and bladder mucosal graft (15). Urinary diversion was provided by open catheter drainage in the latter three groups, and a simple wrap penile dressing was used in all patients. With the exception of the bladder mucosal graft technique, all procedures were performed as outpatients. Results. Complications requiring a second surgical procedure occurred in 28 patients (17%). No patient required rehospitalization during the postoperative period. Conclusions. These results compare favorably to previously reported series utilizing traditional postoperative techniques.

Long-Term Followup of Bladder Mucosa Graft for Male Urethral Reconstruction

Autologous bladder mucosa was used as a free graft for complex urethral reconstruction in 95 male patients, ranging in age from 1 to 21 years. Primary indications for surgery include previous failed hypospadias repair in 68 cases, primary hypospadias in 11, bladder exstrophy/epispadias complex in 10 and others in 6. Patients were divided into 3 groups based on the configuration of the bladder mucosa replacement. Group 1 (37 patients) underwent complete urethral replacement to the tip of the glans. Group 2 (16 patients) underwent placement of a bladder mucosa onlay patch graft. Group 3 (42 patients) underwent a combined repair using tubularized bladder mucosa proximally and either a pedicled preputial tube (6), free preputial or penile skin tube (13), local glandular skin flaps (15), or intact glandular urethra or tubularized urethral plate (8) distally to avoid a terminal segment of bladder mucosa. All patients were followed for a mean of 3.4 years (range 6 months to 8 years).An overall good functional and cosmetic result was eventually achieved in 81 patients (85%). However, 63 patients (66%) required between 1 and 9 (mean 2.7) additional procedures to treat complications before achieving a good result. The most common complications were meatal stenosis and/or prolapse. Meatal problems were significantly more common in group 1 (68%) than in those who underwent a patch or combined procedure (12 and 36%, respectively). Although bladder mucosa provides an excellent and readily available material for urethral substitution in these challenging cases, the urologist should be aware of the significant incidence of postoperative problems and their management. The high incidence of meatal problems suggests that bladder mucosa should not be incorporated as a circumferential terminal urethral segment.

Anterior urethral reconstructions

In the surgical treatment of urethral strictures many techniques have been proposed in the last 30 years. Nowadays, only some of them are currently used, because of complications correlated to these surgical procedures. Of course, our School has also changed indications for surgical procedures in urethral strictures. We can use two different kinds of surgical technique; excision of the stricture with an end-to-end anastomosis or urethroplasty. At the Institute of Urology of the University of Milan, 84 patients underwent end-to-end anastomosis: the 12 months follow-up showed 6 relapsed strictures, 1 fistula and 5 penile ventral flexures. In the field of multi-stage urethroplasty our greatest experience is related to the scrotal inlay technique (144 patients: 36 relapsed strictures, 65 phlogoses, 44 stones), while 18 patients underwent the procedure by the use of free epidermal mesh graft (1 fistula, 2 penile flexures, 2 necrosis of the graft). Concerning the one-stage procedures, the bladder mucosa graft seems to be reliable, and the complications observed were the following: 2 relapsed strictures, 3 fistules, 1 penile flexure; the lip mucosa graft represents a possible alternative: using this technique in 8 patients we had 2 recurrent strictures and 1 fistula. Recently we proposed a modified technique using a tubularlzed penile skin flap for complex, recurrent, extended bulbo-membranous strictures. 24 pts. underwent this surgical procedure. Only two stricture relapses have been found. The first four operated pts. had urethrocystograms which revealed a neourethra exceeding the normal caliber and this was resolved in consecutive cases by reducing the size of the flap.