Buccal Mucosal Graft Urethroplasty Research Articles

Treatment of Meatal Strictures by Dorsal Inlay Oral Mucosa Graft Urethroplasty: A Single-Center Experience.

Background: To report on the use of oral mucosa graft urethroplasty for meatal strictures using the dorsal inlay technique. Methods: Patients who underwent a single-stage dorsal inlay oral mucosal graft urethroplasty between January 2000 and May 2021 were included in this study. A follow-up of a minimum of 12 months was necessary for inclusion. Exclusion criteria were stricture extension into the penile urethra, concomitant stricture at another location, flap urethroplasty for a meatal stricture, dorsal inlay urethroplasty with another type of graft, ventral onlay graft urethroplasty or staged urethroplasty. Recurrence was defined by the inability to pass a 14F metal sound through the reconstructed meatus irrespective of patients’ complaints. Results: Our study cohort included 40 patients. Buccal mucosal graft (BMG) urethroplasty was used in 25 patients and 15 patients were treated with the aid of lingual mucosal graft (LMG). The median follow-up was 85 (IQR: 69–110) months. Seven (17.5%) patients suffered a stricture recurrence of which four (10%) needed re-intervention. The median 5-y recurrent free survival (RFS) for the entire cohort was 85 (±6)%. The median 5-y RFS was 96 (±4)% versus 65 (±13)% for respectively BMG and LMG (p = 0.03). Post-operative complications were identified in 11 (27.5%) patients with only one (2.5%) patient who had a grade 3a complication. Conclusions: Dorsal inlay oral mucosa graft urethroplasty is a safe and feasible technique for selected patients with meatal stenosis.

Multi-Institutional Study of Dorsal Onlay Urethroplasty of the Membranous Urethra after Endoscopic Prostate Procedures: Operative Results, Continence, Erectile Function and Patient Reported Outcomes

(1) Background: To critically evaluate dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for posterior urethral stenosis repair following transurethral resection and other endoscopic prostate procedures. (2) Methods: A retrospective multi-institutional review of patients with membranous or bulbomembranous urethral stenosis for whom treatment with DOBMGU was conducted after receipt of prostate endoscopic procedures. Baseline data, peri-operative care, post-operative care and patient-reported outcomes were analyzed. The primary outcomes were procedural failure and development of de novo stress urinary incontinence (SUI). The secondary outcomes were changes in voiding, sexual function and patient satisfaction. (3) Results: A total of 107 men with a mean age of 69 ± 9.5 years and stenosis length of 3.5 ± 1.8 cm were included. Prior endoscopic procedures among participants were 47 patients (44%) with monopolar TURP, 33 (30.8%) with bipolar TURP, 16 (15%) with Greenlight laser, 9 (8.4%) with Holmium laser enucleation and 2 (1.9%) with bladder neck incision. At a mean follow-up time of 59.3 ± 45.1 months, stenosis recurred in 10 patients (9.35%). Multivariate analysis confirmed that postoperative complications (OR 12.5; p = 0.009), history of radiation (OR 8.3; p = 0.016) and ≥2 dilatations before urethroplasty (OR 8.3; p = 0.032) were independent predictors of recurrence. Only one patient (0.9%) developed de novo SUI. Patients experienced significant improvement in PVR (128 to 60 cc; p = 0.001), Uroflow (6.2 to 16.8 cc/s; p = 0.001), SHIM (11.5 to 11.7; p = 0.028), IPSS (20 to 7.7; p < 0.001) and QoL (4.4 to 1.7; p < 0.001), and 87 cases (81.3%) reported a GRA of + 2 or better. (4) Conclusions: DOBMGU is an effective and safe option for patients with posterior urethral stenosis following TURP and other prostate endoscopic procedures. This non-transecting approach minimizes external urinary sphincter manipulation, thus limiting postoperative risk of SUI or erectile dysfunction.

MP56-16 ONE-STAGE URETHROPLASTY USING DORSAL-VENTRAL BUCCAL MUCOSAL GRAFT: LONG-TERM, VALIDATED PATIENT REPORTED OUTCOMES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III (MP56)1 Sep 2021MP56-16 ONE-STAGE URETHROPLASTY USING DORSAL-VENTRAL BUCCAL MUCOSAL GRAFT: LONG-TERM, VALIDATED PATIENT REPORTED OUTCOMES John Barnard, and Joel Gelman John BarnardJohn Barnard More articles by this author , and Joel GelmanJoel Gelman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002086.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The dorsal-ventral or "double face" buccal mucosa graft urethroplasty (BMG-U) via a dorsal approach was first described in a series of 18 patients in 2014. When the corpus spongiosum is intact, this surgery is appropriate for a 1-stage reconstruction where there is obliteration or near obliteration of a segment too long for anastomotic or augmented anastomotic urethroplasty (AAU). This technique is also a non-transecting alternative to AAU for shorter strictures unsuitable for onlay repair alone. Our objective was to provide global, validated and urethroplasty specific patient reported outcomes (PROMs) with this technique with up to 21 year follow up. METHODS: Patients were prospectively enrolled in our IRB approved urethroplasty outcomes study from 1998 to present. Anatomic success was assessed by cystoscopy >4 months after surgery. Long-term outcomes were assessed using the International Prostate Symptom Score (IPSS) and a 6Q-LUTS urethroplasty specific PROM, the Sexual Health Inventory for Men (SHIM), and the Male Sexual Health Questionnaire Ejaculatory Dysfunction Short Form (MSHQ-EjD-SF). A Student’s t-test evaluated differences in means for the PROMs with significance at p < 0.05. RESULTS: 38 patients underwent BMG-U. Mean age at surgery was 50.5 years (19.2-77.5). Mean follow-up was 78 months (13.4-262.4). The anatomic success rate was 97.2%, and the long-term functional success was 97.4%. Significant improvement was observed in IPSS (including quality of life metric) and 6Q-LUTS post-operatively, and this difference was sustained. No difference in SHIM or MSHQ-EjD-SF was observed. Overall satisfaction was 97.4%, and 91.9% stated they would undergo surgery again knowing their outcome. CONCLUSIONS: The dorsal-ventral BMG-U via a dorsal approach is associated with high patient satisfaction, and validated PROMs demonstrate lasting effect with no significant detriment to erectile and ejaculatory function. It was recently reported that for bulbar strictures, AAU was an independent risk factor for recurrence. Although we did not perform a comparative study, we speculate that the absence of urethral transection may be a factor contributing to a successful outcome that is comparable to the published results for strictures amenable to dorsal onlay substitution urethroplasty. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e975-e975 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Barnard More articles by this author Joel Gelman More articles by this author Expand All Advertisement Loading ...

PD22-09 THE IMPACT OF PREOPERATIVE ORAL HEALTH ON BUCCAL MUCOSAL GRAFT HISTOLOGY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II (PD22)1 Sep 2021PD22-09 THE IMPACT OF PREOPERATIVE ORAL HEALTH ON BUCCAL MUCOSAL GRAFT HISTOLOGY Jane Kurtzman, Sun-Ming Pan, Shawn Mendonca, Shyam Sukumar, Yue Lai, and Steven Brandes Jane KurtzmanJane Kurtzman More articles by this author , Sun-Ming PanSun-Ming Pan More articles by this author , Shawn MendoncaShawn Mendonca More articles by this author , Shyam SukumarShyam Sukumar More articles by this author , Yue LaiYue Lai More articles by this author , and Steven BrandesSteven Brandes More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002011.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Oral mucosa is the first choice for urethral augmentation in patients undergoing urethroplasty for stricture disease. Previous studies have elucidated the unique anatomic and histologic properties of oral mucosa which make it a viable and durable graft, as well as established criteria and contraindications for selecting patients for oral graft harvesting. However, no prior literature has investigated the impact of preoperative oral health on buccal mucosal histology and graft take. METHODS: We analyzed all consenting patients who underwent buccal mucosal graft (BMG) urethroplasty at our institution from 2018-2020. Validated oral health surveys, the Oral Health Impact Profile (OHIP-14) and the Kayser-Jones Brief Oral Health Status Exam (BOHSE) were completed preoperatively. A staff pathologist analyzed BMG histology and quantified oral mucositis (OM) using a modified Oral Mucosa Rating Scale. Each patient underwent a retrograde urethrogram (RUG) at postoperative week 3 to assess for a urinary leak. Individual age-adjusted linear regression models were used to explore the association between BOHSE, OHIP-14 and OM and BMG epithelial thickness, lamina propria thickness and delta stretch. RESULTS: We analyzed 51 patients, median age 40 years (IQR 31–58). Mean BOHSE score was 1.1 and OHIP-14 score was 1.4. 37 grafts were assessed in pathology. Median epithelial thickness was 530 microns and lamina propria thickness was 150 microns. Age-adjusted linear regression demonstrated that as BOHSE score, OHIP-14 score and OM score increased (i.e. oral health worsened), average epithelial thickness of the grafts decreased (p=0.001; p=0.01; p=0.05, respectively). Higher BOHSE scores also significantly correlated with thinner average lamina proprias (p=0.05) and decreased delta stretch lengthwise (p=0.028). The two patients with postoperative urine leaks and pathology available for review had elevated OM scores and lamina propria thicknesses well-below the cohort median, 50 microns and 60 microns, respectively. CONCLUSIONS: This is the first study to demonstrate that oral health conditions impact graft histology and stretch. Though much remains to be learned, our finding that worse oral health conditions correlate with adverse histology emphasizes the importance of optimizing preoperative oral health and raises the question of if preoperative mucosal biopsy could help inform surgical decision making and discussions regarding surgical success. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e383-e383 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jane Kurtzman More articles by this author Sun-Ming Pan More articles by this author Shawn Mendonca More articles by this author Shyam Sukumar More articles by this author Yue Lai More articles by this author Steven Brandes More articles by this author Expand All Advertisement Loading ...

The outcomes of three buccal mucosal graft urethroplasty techniques in women with urethral stricture disease.

The purpose of this paper is to present the outcomes of three buccal mucosal graft (BMG) urethroplasty techniques in female patients with urethral strictures. We included all patients who had BMG urethroplasty for female urethral strictures (FUS) disease between January 2015 and June 2020. Patient age, comorbidities, stricture etiology, stricture length, the number of previous treatments, preoperative and postoperative uroflowmetry data, postvoid residual volumes, and the operation and postoperative course details were documented. A total of 34 patients were included in this study. There were 8 patients in vaginal-sparing inlay BMG, 12 for ventral onlay BMG, and 14 for Aybek-Zumrutbas (AZ) technique groups. The mean age of the study population was 56.1 years. The length of urethral strictures varied between one and 4.5 cm. All patients had a previous history of endoscopic treatment or dilatations. The preoperative mean maximal flow rate (Qmax) was 6.9 ml/s. The median postoperative follow-up time was 24.6 months. Twelve months after surgery, the mean Qmax was 25 (range: 14-32) ml/s. There were no significant complications in any patients. The success rates were 83.3% for ventral onlay BMG, 87.5% for vaginal-sparing, and 100% for AZ technique. All three BMG urethroplasty techniques applied in this study had a success rate of over 80% in a median follow-up of approximately 2 years. In females, urethroplasty with BMG provided high rates of cure, and the recently described two techniques (vaginal-sparing inlay BMG, and AZ technique) showed promise in FUS treatment.

Treatment of panurethral strictures using one side dissection dorsal onlay buccal mucosal graft urethroplasty

The management of panurethral stricture was still challenging and controversial. We presented a case of pan urethral strictures management by using a one-sided dissection of dorsal onlay buccal mucosal graft (BMG) urethroplasty (Kulkarni technique). A 53-years old man admitted with panurethral stricture who had previously undergone several procedures. Bipolar micturition cystourethrography procedure revealed 17 cm stricture length. One-sided dissection dorsal onlay buccal mucosal graft urethroplasty was performed. No drain was placed. The Foley catheter was removed four weeks after surgery, and the results of the micturition were favourable. No fistulae were found at a straight erection and meatus at a normal position. The postoperative flow rate (Qmax) was 24.9 ml/second. As a conclusion Kulkarni technique urethroplasty gained good outcome for panurethral stricture in our case.

Evaluation of the Extent of Primary Buccal Mucosal Graft Contracture in Augmentation Urethroplasty for Stricture Urethra: A Prospective Observational Study at a Tertiary Healthcare Centre.

Introduction Buccal mucosal graft (BMG) urethroplasty is considered as gold standard in the treatment of urethral stricture disease. The successful outcome after BMG urethroplasty varies between 66 and 99%. One of the possible causes for failure is BMG contracture. Primary BMG contracture rate is poorly understood and unreported. The present study aimed to evaluate the extent of contracture of buccal mucosa immediately after harvesting. Materials and Methods This was a prospective observational study conducted in the Department of Urology at our institute between January 2016 and December 2019. All patients with urethral stricture disease undergoing BMG urethroplasty for the first time were enrolled in the study after obtaining informed consent. Demographic and patient clinical profile was noted. Based on the intraoperative urethral stricture size, the preharvest graft was marked on the buccal mucosa and the size was calculated. Postharvest unstretched size of the graft was measured immediately after graft removal from the oral cavity. Alteration in BMG size was analysed using paired t-test. Results Forty-four patients were included in the study. Mean age of the patient was 53.6 years. Mean stricture length was 7.45 cm (range 4–12 cm). Mean pre- and postharvest BMG size was 8.3 × 1.5 cm and 7.6 × 1.3 cm, respectively. There was a 8.4% decrease in length and 9.5% decrease in width of the buccal mucosal graft. Conclusion Primary buccal mucosal graft contracture is around 8.4% in length and 9.5% in width. It would be better to mark wider than necessary while harvesting buccal mucosa so that tension-free anastomosis is performed.

Editorial Comment.

You have accessJournal of UrologyReview Article1 Oct 2021Editorial CommentThis article comments on the following:One-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-Analysisis a letter which has replyReply by Authors Benjamin Dropkin Benjamin DropkinBenjamin Dropkin Department of Urology,University of Kentucky,Lexington, Kentucky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001870.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Minimally invasive treatment options for LS strictures include topical and intraurethral steroids and extended meatotomy. Urethroplasty is required if these treatments fail. Substitution urethroplasty using genital skin flaps performs poorly in the setting of LS and has been strongly discouraged (reference 33 in article). Two-stage repair utilizing BMG demonstrated reasonable long-term success rates and became the standard of care. The requisite second procedure, substantial revision rate, and potential for cosmetic and sexual ramifications are inconveniences that could potentially be avoided with a single-stage BMG technique, which has proven to be highly successful for non-LS strictures. Whether similar results can be achieved in the LS population remains a topic of debate among reconstructive urologists. The meta-analysis by Kurtzman et al offers the strongest available support for the use of single-stage BMG urethroplasty in the treatment of LS strictures. The authors analyzed 21 retrospective case series that included 625 LS patients treated with single-stage BMG urethroplasty and found a pooled stricture recurrence rate of 10%, which rose to 18% when the analysis was limited to studies with at least 24 months of followup. A subanalysis of the studies that reported outcomes from groups of men with LS and non-LS strictures found similar short-term recurrence rates and marginally poorer outcomes in LS cases with >24 months of followup. Of note, LS-strictures involving the penile urethra were significantly less likely to recur when approached via a perineal incision with penile invagination. Several limitations are notable. This study did not include an assessment of series reporting outcomes for 2-stage urethroplasty for LS strictures. Additionally, the authors appropriately advise caution in applying the results of this meta-analysis to patients with severe stricture disease, who lack a viable urethral plate and/or demonstrate a urethral lumen less than 5Fr. © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyMay 25, 2021, 12:00:00 AMOne-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-AnalysisJournal of UrologyJul 23, 2021, 12:00:00 AMReply by Authors Volume 206Issue 4October 2021Page: 851-852 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benjamin Dropkin Department of Urology,University of Kentucky,Lexington, Kentucky More articles by this author Expand All Advertisement Advertisement Loading ...

Paediatric Buccal Mucosal Graft Urethroplasty for Non-Hypospadias Urethral Strictures: A Single Centre Experience with Long Term Outcomes

ObjectiveTo review our experience in the management of paediatric urethral strictures with buccal mucosal graft urethroplasty and its long term outcomes. MethodsThis was a retrospective analysis of a prospectively maintained data base between 2009–2019. Circumcised children with long segment urethral strictures (> 1.5 cm) were included. They were characterized as either peno-bulbar (PBS) or isolated bulbar strictures (IBS) based on a standardized protocol. All children underwent single stage dorsal onlay buccal mucosal graft urethroplasty by either the Kulkarni technique (PBS group) or the Barbagli technique (IBS group). All children were followed up at 3 months, then annually thereafter with flow rates at each visit. Success was defined as a flow rate > 10ml/sec with a bell-shaped curve and absence of need for any secondary procedures. Results28 children underwent buccal mucosal graft uretheroplasty.16 children were diagnosed with PBS & 12 children with IBS. The median age was 7.5 years (2–17 years) in PBS and 5.5 years (3–10 years) in IBS. Iatrogenic injury was the commonest aetiology ie 71 % (20/28). Mean length of stricture was 4 cm (3–5.5 cm) in PBS and 2.5 cm (2–3.5 cm) in IBS. Median follow up was 96 months (24-120 months) in PBS and 90 months (36-120 months) in IBS. The success rate was 87.5% (14/16) in PBS and 83.3% (10/12) in IBS. ConclusionSingle stage dorsal on lay buccal mucosal graft urethroplasty, ie Kulkarni and Barbagli techniques are safe and feasible in children with long segment urethral strictures with good long-term outcomes.

One or Two Stage Buccal Augmented Urethroplasty has a High Success Rate in Treating Post Phalloplasty Anastomotic Urethral Stricture

ObjectiveTo describe the outcomes of single-stage and staged repairs in properly selected patients with phalloplasty anastomotic strictures. MethodsA bi-institutional retrospective review was performed of all patients who underwent anastomotic stricture repairs between 7/2014-8/2020. Those who had prior augmented urethroplasties or poorly vascularized tissue underwent two-stage repairs (Group-2), all others underwent single-stage repair with a double-face (dorsal inlay and ventral onlay) buccal mucosal graft urethroplasty (Group-1). Postoperatively, urethral patency and patient reported outcome measures (PROMs) were assessed. ResultsTwenty-three patients with anastomotic strictures were identified. Fourteen patients met inclusion criteria and had 1-year follow-up (9 in Group-1; 5 in Group-2). Nine patients (64%) had prior failed interventions (56% Group-1; 80% Group-2). At a mean follow-up of 33.9 (Group-1) and 35.2 months (Group-2) there were two stricture recurrences in Group-1 (22%) and none in Group-2. PROMs were completed by 12 patients. All patients reported the ability to void standing. Post-void dribbling was present in the majority of patients (7/7 Group-1; 2/4 in Group-2). Mean IPSS was 3.9 (0-14) for Group-1 and 1 (0-3) for Group-2. All reported at least a moderate improvement in their condition on GRA (Group-1 +3 71%, +2 29%; Group-2 +3 100%). ConclusionSingle-stage repairs are feasible for patients with anastomotic strictures who have well vascularized tissue and no prior single-stage buccal mucosa augmented urethroplasty failures. Staged repairs are feasible for patients with poor tissue quality. Proper patient selection is important for successful reconstruction.

One-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-Analysis.

Performing 1-stage urethroplasty in patients with urethral strictures caused by lichen sclerosus (LS) is hotly debated among reconstructive urologists due to conflicting reports of success. Therefore, the objective of this study was to determine the pooled incidence of stricture recurrence following 1-stage buccal mucosal graft (BMG) urethroplasty in patients with LS, to determine the impact of surgical technique on recurrence and to compare recurrence risk between patients with and without LS after 1-stage repairs. A systematic review was conducted in accordance with PRISMA criteria. The primary outcome was pooled incidence of recurrence, which was calculated using a Der-Simonian-Laird binary random effects model with a Freeman-Tukey arcsine transformation. A total of 21 studies were included, of which 15 provided data for comparative analyses. Pooled data from 625 LS patients revealed a stricture recurrence rate of 10% (95% CI 6-14). Among studies with longer followup (≥24 months), this increased to 18%. Among patients with penile urethral involvement, studies utilizing a penile skin incision had significantly higher pooled recurrence rates than those utilizing penile invagination (p=0.004). Across all studies, there was no evidence to suggest a difference in pooled recurrence rate between patients with and without LS (p=0.36). However, across only long-term studies, recurrence risk was significantly higher for patients with LS (OR 1.83, p=0.05). One-stage BMG urethroplasty is likely a viable surgical option for patients with LS-related strictures; however, high-quality data are limited. Future multi-institutional, long-term prospective studies are needed to assess durability of 1-stage repair.

Outcome of dorsal buccal graft urethroplasty in female urethral stricture disease (FUSD); our institutional experience.

Female urethral stricture is a poorly studied disease entity. To date, its management has been poorly evaluated, with small numbers and various definitions of success. Treatment options traditionally have been urethral dilatation and/or self-catheterization with success rates ranging from only 14 to 49%. However, there has been increasing use of urethroplasty due to the improved success rate (70 to 100%). In this study we assessed the outcome of dorsal buccal mucosal grafts in female urethral stricture disease. In our study we prospectively analyzed 25 female patients treated from 2014 to 2019 at our institute; ages ranged from 26 to 66years. Dorsal buccal mucosal graft urethroplasty was performed in all patients. The pathology of female urethral stricture disease is unknown, and neither the pre- nor the intraoperative assessment allows determining the precise location and extent or the severity of urethral damage; therefore, we advocate extensive grafting of the entire urethra. Patients were followed every 3 months during the 1st year and then biannually with lower urinary tract symptom, uroflowmetry and post-void residual urine assessments. Stricture recurrence (failure) was defined as recurrence of symptoms, no change or reversal in Qmax and post-void residual urine values and failure of negotiation of a 17-Fr cystoscope. Success rate of our surgical intervention was > 90%. We observed that the mid-urethra was the most common location of the stricture. Stricture location was confined to the distal urethra in 12%, the mid-urethra in 16%, spanned the distal mid-urethra in 16%, spanned the mid-proximal urethra in 40% and spanned the pan-urethra in 16%. Mean stricture length was 1.8 (0.7-2.1)cm. Mean pre- versus postoperative Qmax was 5ml/s versus 23.3ml/s and mean residual urine was 178ml versus 18.5ml. Two patients had stricture recurrence at 3months post-intervention. Dorsal buccal mucosal graft currently represents a prime choice for female urethral stricture reconstruction, keeping in view the advantages of the procedure such as easy availability of the graft and fewer donor site comorbidities. We emphasize upfront urethroplasty and extensive urethral grafting.

Safety and Efficacy of Trans-Perineal Urethroplasty for Management of Post-Traumatic Urethral Strictures in Pediatric Age-Group

Introduction: Trans-perineal urethroplasty is the preferred treatment for distraction urethral injuries in adults. However, management of such injuries in children is challenging because of functional implications in a growing child. In the present study, we aim to evaluate the safety and efficacy of perineal urethroplasty for distraction urethral injuries in children. Methods: The medical records of prepubertal pediatric patients (age <14 years) with traumatic urethral distraction injuries managed by perineal urethroplasty were retrospectively reviewed and analyzed with respect to demographics, stricture characteristics, management, complications, follow-up, and outcome. Results: A total of 14 patients were included in the study. Ten had membranous, and 4 had bulbar urethral strictures. All membranous strictures were secondary to pelvic trauma; bulbar strictures were secondary to blunt perineal trauma; 7 patients had associated pelvic fractures. Anastomotic urethroplasty was used in 10 patients (71.4%) and buccal mucosal graft urethroplasty was done in 4 patients (38.6%). The mean follow-up duration was 56 months (range 24–76). Surgery was primarily successful in 85.7%. Failed repair in 2 patients was successfully managed with augmented anastomotic urethroplasty. Post-operatively, the mean maximal urinary flow rate was 26.4 mL/s. No significant complications occurred. All boys are continent. There was no chordee or urethral diverticula, during follow-up. Conclusion: In pediatric patients, bulbar and membranous strictures can be treated successfully with urethroplasty using the perineal approach. Longer follow-up is needed to confirm that these good results are maintained as these patients cross into adulthood, especially as these repairs were done before puberty.

Risk factors associated with urethral stricture recurrence after end-to-end urethroplasty and buccal mucosal graft urethroplasty.

(1) Assess risk factors associated with urethral stricture recurrence (USR). (2) Assess urethral stricture recurrence after end-to-end urethroplasty (EE) and buccal mucosal graft urethroplasty (BMG). A total of 29 males with urethral stricture who underwent either an end-to-end urethroplasty or a buccal mucosal graft urethroplasty were included in this study and followed for 18 months. The association between risk factors and stricture recurrence was assessed. Overall mean patient age was 51.69 ± 14.22 years, time to recurrence was 3 months (IQR: 1-6.25), and stricture length was 2.57 ± 1.30 cm. Important risk factors for USR were stricture length ⩾ 2 cm (p = 0.024), older age (p = 0.042), BMI > 25 kg/m2 (p = 0.021), Qmax after catheter removal <15 ml/s (χ2 = 14.87 p ⩽ <0.001) and previous urethral procedures adjusted for re-do BMG urethroplasty (χ2 = 6.10, p = 0.021). End-to-end urethroplasty showed less USR than BMG, however, these differences were not statistically significant (41.6% vs 22.2%, respectively, p ⩾ 0.05). Stricture length, age, BMI, and previous urethral procedures predict USR, furthermore, an initial Qmax after catheter removal is an objective measure predictive of USR. There's no difference in USR rate between BMG and EE urethroplasties.

Exploring the intersection of functional recurrence, patient-reported sexual function, and treatment satisfaction after anterior buccal mucosal graft urethroplasty

PurposeTo evaluate the interplay of stricture recurrence, sexual function, and treatment satisfaction after substitution urethroplasty.MethodsObservational study of men undergoing 1-stage buccal mucosal graft urethroplasty for anterior urethral stricture between 2009 and 2016. Patients were dichotomized by self-reported treatment satisfaction. Sexual function was assessed by validated and non-validated patient-reported outcome measures. Functional recurrence was defined as symptomatic need of re-intervention. Bivariate analyses, Kaplan–Meier estimates, qualitative and quantitative analyses by uni- and multivariable regression were employed to evaluate the interplay of sexual function, functional recurrence, and treatment satisfaction.ResultsOf 534 men with bulbar (82%), penobulbar (11%), and penile strictures (7.3%), 451 (84%) were satisfied with the surgery. There were no differences in stricture location, previous treatment, graft length, or surgical technique between satisfied and unsatisfied patients (all p ≥ 0.2). Recurrence-free survival was 85% at a median follow-up of 33 mo and decreased significantly with each Likert item towards increasing dissatisfaction (p < 0.001). Dissatisfied patients more often reported postoperative loss of rigidity, tumescence, reduced ejaculatory volume, ejaculatory pain, and reduced penile length (all p ≤ 0.042). In 83 dissatisfied men, functional recurrence (28%) and oral morbidity (20%) were the main drivers of dissatisfaction in qualitative analysis. Multivariable analyses revealed functional recurrence and impaired postoperative ejaculatory function as independent predictors of treatment dissatisfaction (all p ≤ 0.029) after adjusting for confounders.ConclusionWe found an association of both functional success and sexual function with patient-reported treatment satisfaction after substitution urethroplasty. Such findings validate the clinical significance of defining the symptomatic need for re-intervention as an endpoint and underline the importance of further research evaluating sexual function before and after open urethral reconstruction.

Preoperative and intraoperative factors predictive of complications and stricture recurrence following multiple urethroplasty techniques

ObjectivesTo investigate factors predictive of postoperative recurrence and complications in patients undergoing urethroplasty for stricture repair at a single center.Patients and methodsWe retrospectively reviewed the records of 108 men who underwent urethroplasty for urethral stricture disease (USD) at a single center from 2016 to 2020. Demographic data, comorbidities, stricture history including etiology and prior treatments, patient‐reported symptoms, and outcomes data were collected for analysis. Data were analyzed in aggregate, then, stratified by type of urethroplasty performed. Descriptive statistics, univariate analysis, multivariate logistic regression, and intergroup comparisons were completed using STATA, with an alpha value of 0.05 and a confidence interval of 95%.ResultsThe median age of our patients was 58 years (interquartile range: 42‐69; range: 29‐83), with a median stricture length of 2.0 cm (interquartile range: 1.0‐4.5; range: 0.5‐10). The most common stricture etiology was iatrogenic (n = 33, 31%) and the most common urethroplasty was anterior anastomotic urethroplasty (n = 38, 35%), followed by buccal mucosal graft (BMG) urethroplasty (n = 35, 32%). Twenty‐four patients (22%) had stricture recurrence. Within the aggregate data, recurrence was significantly predicted by obesity (BMI > 30) (Odds Ratio [OR] 3.2, 95% Confidence Interval [CI]: 1.06‐10), and the presence of postoperative complications (OR 6.3, CI: 1.9‐21). The presence of any postoperative complications within 90 days was significantly predicted by stricture length ≥ 5 cm (OR 3.5, CI 1.09‐12) and recurrence (OR 6.0, CI 1.7‐21).ConclusionDespite serving as the most definitive treatment for urethral stricture management, stricture recurrence and postoperative complications are not uncommon after urethroplasty. Obesity and stricture length negatively impact outcomes while a penile stricture location is associated with a lower recurrence rate, though this is not statistically significant.

Dorsolateral inner preputial graft urethroplasty for anterior urethral strictures: long-term outcomes from a single tertiary care centre.

PurposeBuccal mucosa graft (BMG) is long used as favoured substitute by most reconstructive surgeons for substitution urethroplasty (SU). Though inner preputial skin graft (IPG) was described even earlier than BMG, its usage lately has fallen out of favour. The aim of the study was to evaluate the outcome of a SU with IPG from a tertiary care centre.MethodsA retrospective analysis of prospectively maintained clinical data was conducted at our tertiary care centre enrolling 80 patients with anterior urethral stricture from January 2015 to January 2018. Patients were evaluated for the aetiology, length and site of the urethral stricture. All patients underwent dorsolateral SU with IPG. Post-operative assessment including uroflowmetry and sexual outcomes using IIEF and MSHQ-EJD questionnaires was done at 3 weeks, 3 months, 12 months and half-yearly thereafter. Success was defined by the stable maximum urinary flow value > 14 ml/s or urethral calibration with 16 French Foley catheter.ResultsMean age of patients was 40 years (18–69). The most common aetiology was post-instrumentation (65%) and 60% had stricture at penobulbar site. Mean stricture length was 65 mm. At a mean follow-up of 48 months (range 30–66 months), successful outcomes were seen in 69/80 (87%). Patients with failure were managed with optical internal urethrotomy (OIU). Uroflowmetry and obstructive symptoms significantly improved and sexual function remained unaffected using IPG for SU.ConclusionsPreputial graft is a tissue familiar to the urologist, located very close to the surgical field, easily harvested and operated under regional anaesthesia. Overall success outcomes are acceptable to BMG urethroplasty.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00345-021-03613-9.

Ventral onlay buccal mucosa graft urethroplasty for female urethral stricture.

Female urethral stricture is a rare disease. Urethroplasty with different techniques using grafts or flaps are successful treatment options. The objective of this study was to present our experience with ventral onlay buccal mucosa graft urethroplasty for the treatment of female urethral stricture disease. Eight female patients treated with ventral onlay buccal mucosa graft urethroplasty were identified retrospectively. Patient evaluation included physical examination, uroflowmetry with postvoid residual urine measurement, videourodynamics and urethrocystoscopy. Stricture was identified by videourethrography and/or urethrocystoscopy. Urodynamic evidence of stricture was considered as a persistent low maximum flow rate of <12mL/s combined with detrusor pressure at maximum measured flow rate of >20cmH2 O in the pressure flow study. The mean age was 50.5±4.14years. Stricture etiology was idiopathic (62.5%) or iatrogenic (37.5%). Two patients (25%) had undergone prior urethral dilations before buccal mucosa graft urethroplasty. Mean stricture length was 1.62±0.44 cm. Stricture location was as follows: four distal urethra (50%), two mid-distal (25%) and two mid-urethra (25%). The mean postoperative follow-up period was 16.37±5.75months, and the during follow-up success rate was 100%. No complication, such as incontinence or vaginal fistula, was noted, except dyspareunia developed in one patient (12.5%). Ventral onlay buccal mucosa graft urethroplasty is a safe and effective treatment option for female urethral stricture. Unnecessary dilation should not be carried out and buccal mucosa graft urethroplasty in expert centers should be recommended to these patients.

Outcome of dorsal versus ventral onlay buccal mucosa graft urethroplasty in female urethral stricture

Female urethral stricture (FUS) yet one that can cause significant bothersome lower urinary tract symptoms (LUTS) represents an uncommon condition. A variety of reconstructive surgical techniques have been described in recent years to provide more definitive in this challenging group. Aim of the study: The aim of this study was to find out the outcome of dorsal and ventral onlay buccal mucosa graft (BMG) urethroplasty in female urethral stricture disease. Methods: This Quasi experimental study was conducted in the Department of Urology, Dhaka Medical College Hospital Dhaka during the period from July, 2018 to June, 2020. Total 30 patients with moderate to severe bothersome LUTS due to mid and/or distal urethral stricture were included in the study as per inclusion and exclusion criteria. Patients were divided into two groups. Group-A for dorsal onlay and Group-B for ventral onlay buccal mucosa graft urethroplasty to every alternate sequence. All women were evaluated preoperatively, as per predefined criteria. As failure of the treatment, increase in AUA symptom score, maximum flow rate (Qmax)

Study of etiology, clinical presentation, management procedures performed and complications of urethral stricture patients at a tertiary hospital

Background: Urethral stricture is narrowing of a segment of the urethra which is surrounded by corpus spongiosum. The overall incidence of stricture disease varies from 0.6% to 0.9% worldwide. Urethral stricture obstructs lower urinary tract, causes micturition disturbances, can also damage the entire urinary tract, resulting in loss of renal function. In present study we aimed to study etiology, clinical presentation, management procedures and complications of urethral stricture at a tertiary hospital. Material and Methods: Present study was single-center, prospective, observational study, conducted patients diagnosed to have urethral strictures, underwent initial management during the study period and willing to participate. Patients treated by dilatation, Direct vision internal urethrotomy (DVIU), open surgery (urethroplasty). Results: This study included 50 patients of male and female genders of different age groups. Male to female ratio was 3.55 : 1. Maximum patients (32%) were from the age-group 31-40 years with mean age of 45.7 +16.59 years. Causes of urethral stricture in most of the patients were infections (30%) and trauma (50%). Most patients are treated by the serial urethral dilatation (58%). Other procedures were visual internal urethrotomy (VIU) (26%) and surgery including buccal mucosal graft (BMG) urethroplasty (16%). Postoperatively out of 50 patients 7 patients experienced Pain [14%] and 43 patients doesn‘t have pain in postoperative period. [86%]. About 8 patients have fever in postoperative period [16%] and hematuria is seen in 18 patients [36%]. Conclusion: Trauma and infections were the leading cause of urethral stricture. Visual Internal Urethrotomy and urethroplasty were the mainstay of treatment with satisfactory outcome.