Buccal Mucosal Graft Harvest Site Research Articles

Comparison of Closure Versus Non-Closure of Buccal Mucosal Graft Harvest Site Outcomes in Urethroplasty

Comparison of Closure Versus Non-Closure of Buccal Mucosal Graft Harvest Site Outcomes in Urethroplasty

A Systematic Review of Randomized Controlled Trials Comparing Buccal Mucosal Graft Harvest Site Non-Closure versus Closure in Patients Undergoing Urethral Reconstruction.

PurposeTo assess the effects of buccal mucosal graft site non-closure versus closure on postoperative oral morbidity for male undergoing augmentation urethroplasty for urethral stricture.Materials and MethodsWe included randomized controlled trials. Inclusion criteria were male over the age of 18 with urethral stricture disease requiring reconstruction with buccal mucosal graft harvest. Primary outcomes of the review were postoperative oral pain, need for secondary oral procedures and cosmetic defects.ResultsWe included 5 studies with 346 randomized patients with urethral strictures, of whom 260 completed the trials. In terms of primary outcomes, non-closure graft site may reduce oral pain on postoperative day #1 (standard mean difference [SMD] 0.24 lower; 95% confidence interval [CI] 0.61 lower to 0.12 higher; low certainty evidence [CoE]) but we are uncertain how this impacts pain on postoperative days 3 to 6 (SMD 0.35; 95% CI 0.12 to 0.81 higher; very low CoE). We are also very uncertain as to how it affects the need for secondary oral procedures (risk ratio [RR] 0.22; 95% CI 0.01 to 4.28; very low CoE). Non-closure may increase the risk of cosmetic defects (RR 2.40; 95% CI 0.93 to 6.22; low CoE).ConclusionsThis review describes the trade-off for buccal mucosal graft site non-closure versus closure for various patient-important outcomes; decision-making will likely hinge on the relative value individual patients and surgeons place on them. The supporting evidence was rated as low and very low, thereby signaling substantial underlying uncertainty and the need for better trials.

Outcome of Non-Closure of Buccal Mucosal Graft Harvest Site in Comparison to Primary Closure

Objective: To compare prospectively the outcome of non-closure of buccal mucosal graft harvest site in comparison to its’ primary closure. Methods: Patients who underwent BMG harvest for urethroplasty were randomized into 2 groups; in group 1 donor site was closed and in group 2 it was left open. Pain at BMG harvest site was the primary variable. Postoperative resumption to regular diet and difficulty in mouth opening were 2 other variables. After buccal mucosal graft harvesting, donor area was either closed (group 1) or left open and allowed to heal by second intention. In the postoperative period, visual analog score was to evaluate pain at donor area. Self made questionnaires were used to assess limitation to mouth opening andthe time to resumption of liquid and solid diet. Results: Thirty two patients were studied, 16 in each group from December 2012 to June 2014. Mean age among the two groups were almost same(closure group, 42.37 years Vs 41.26 years in nonclosure group). Mean stricture length was 4.75 cm in closure group and 7.53 cm in non -closure group. In closure group, BMG was harvested from single cheek in most of the patients but in non closure group, graft was harvested from both cheeks and also from lower lips in few patients. Mean post operative pain score was 5.06 and 3.68 at day 1 in group 1 and group 2, respectively (P < 0.008) but as the days progressed, pain score in both groups became comparable. Return to oral intake in terms of liquid and solid diet was comparable between the groups. Difficulty with mouth opening was maximal during the first week with no difference among the two groups. Conclusion: Pain appears to be worse in the immediate post operative period with suturing of the harvest site. There is no difference in long term morbidity whether the graft site is closed or left open. It may be best to leave buccal mucosa harvest sites unsutured. Bangladesh Journal of Urology, Vol. 20, No. 1, January 2017 p.26-30

Liposomal Bupivacaine Local Infiltration for Buccal Mucosal Graft Harvest Site Pain Control: A Single-blinded Randomized Controlled Trial

ObjectiveTo assess efficacy and safety of liposomal bupivacaine (LB) infiltration of the buccal mucosal graft (BMG) harvest site in alleviating pain by evaluating the postoperative narcotic usage, pain score, and morbidities. Patients and MethodsSingle-blinded randomized controlled trial of 43 adult patients for BMG substitution urethroplasty between January 2015 to June 2017 (Clinicaltrials.gov: NCT03720223). A computer-generated allocation scheme randomized patients to control group (n = 22) no further local anesthetic infiltration aside from that of used in the hydrodissection for BMG harvest, and to intervention group with additional infiltration of LB to BMG harvest site (n = 21). We assessed postoperative cumulative narcotic use on post-op day 1 and 2 (24- and 48-hour total intravenous [IV] morphine equivalents in milligrams). A self-reported 10-point numeric rating scale survey was administered to assess postprocedural oral pain, oral conditions, and morbidity on days 1-3, and at 1-month follow-up. Fisher's exact test and independent T test were performed to assess differences between treatment groups. Linear regression was used to determine adjusted effect estimates of intervention. ResultsCompared to controls, a significantly lower narcotic use was noticed among the LB treatment group on post-op day 1 (IV morphine equivalent mean difference 8.58 mg; 95% confidence interval 1.59, 15.56, P =.017), while no significant difference was noticed on post-op day 2. There was no significant difference between treatment groups with regards to postprocedural oral pain score or oral morbidities. ConclusionOur study showed that LB infiltration of the BMG harvest site is safe and associated with lower 24-hour narcotic use only at post-op day 1.

Re: Nonclosure versus Closure of Buccal Mucosal Graft Harvest Site: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes.

Re: Nonclosure versus Closure of Buccal Mucosal Graft Harvest Site: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes.

Nonclosure Versus Closure of Buccal Mucosal Graft Harvest Site: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes

To compare the postprocedural oral pain scale and other patient reported oral morbidities for nonclosure vs closure of buccal mucosal graft (BMG) harvest sites through systematic review and meta-analysis of comparative studies. A systematic literature search was performed in September 2018. Nonrandomized comparative studies were summarized and randomized controlled trials were evaluated according to the Cochrane Collaboration recommendations. The outcomes assessed were: pain, perioral numbness, mouth opening tightness, and impairment of oral intake. Standardized mean difference, and relative risk with corresponding 95% confidence intervals were extrapolated. Effect estimates were pooled using the inverse variance method with a random-effects model. Subgroup analysis was performed according to the shape of the BMG harvested. PROSPERO registry (CRD42016043502). A total of 269 patients from 4 randomized controlled trials were included for meta-analysis. Overall pooled effect estimates on the reported pain score assessed on postprocedural day 1, day 3-7 and 6 months, have shown no significant difference between the closure and nonclosure treatment groups. Subgroup analysis showed that rectangular shaped BMG harvest sites that were not closed had lower pain scores (standardized mean difference-0.90, 95% confidence interval -1.70, -0.10) on postoperative day 1. No reported short or long-term oral morbidities required further surgical intervention in either treatment group. The evidence suggests that at 6-month follow-up, there is no overall significant difference between nonclosure and closure of BMG harvest sites. However, among rectangular shaped BMG, not closing the harvest site may lead to less immediate postoperative pain when compared to closure of the harvest site.

Urethroplasty Practice Patterns of Genitourinary Reconstructive Surgeons

IntroductionTo our knowledge there are no studies evaluating urethroplasty practice patterns among genitourinary reconstructive surgeons. MethodsAn electronic survey was sent to members of the Society of Genitourinary Reconstructive Surgeons. Respondents were queried regarding approach to bulbar urethral reconstruction in 6 index cases. ResultsA total of 91 society members who regularly treated men with urethral strictures responded to the survey. For a 1.5 cm stricture excision and primary anastomosis was the preferred treatment, although less unanimously than expected (only 83% in older men and 67% in younger men). For 2.5 cm strictures urethroplasty with buccal mucosal graft was the preferred treatment for a 35-year-old man, and excision and primary anastomosis for a 65-year-old man. Excision and primary anastomosis was preferred less frequently in younger patients and in patients with longer strictures (Cochran Q test, p <0.001). No other variables were independently associated with use of excision and primary anastomosis, but there were trends toward increased use of excision and primary anastomosis in higher volume surgeons and surgeons who trained fellows. Of the respondents 90% harvest their own buccal grafts, with 46% leaving harvest sites open and 36% closing them. Of the respondents 48% use stricture location to determine graft placement, while 33% use dorsal onlay and 19% use ventral onlay when substitution urethroplasty is chosen. ConclusionsUrethroplasty consisting of excision and primary anastomosis is performed less commonly than expected among genitourinary reconstructive surgeons. Considerable variation exists regarding operative technique, management of buccal mucosal graft harvest site and substitution onlay site.

Prediction of Early and Late Complications after Oral Mucosal Graft Harvesting: Multivariable Analysis from a Cohort of 553 Consecutive Patients

We investigated the early and late complications after oral mucosal graft harvesting, and reported the independent predictors of outcome via multivariable analysis. We performed a retrospective descriptive study of 553 patients from whom an oral mucosa graft was harvested for urethroplasty from single or bilateral cheeks. Patients who underwent oral mucosa harvesting from the lip, the tongue or from the cheek and lip at the same time were excluded from analysis. The oral graft was harvested in an ovoid shape with closure of the wound. Postoperative early and late complications were investigated using a self-administered, nonvalidated, semiquantitative questionnaire. There were 6 questions on early complications, and 13 questions investigated late complications and patient satisfaction. Descriptive statistics of categorical variables focused on frequencies and proportions. Univariable and multivariable analyses were used to predict early and late dissatisfaction of patients. Bleeding was reported in 3.4% of patients. Overall 53.2% of patients did not report any pain and 36.3% reported no swelling. Late complications analysis showed that 95.5% of patients declared that the surgical closure of the wound did not cause any difficulty in opening the mouth or problems with smiling (98.2%) and/or dry mouth (95.8%). Overall 98.2% of patients were satisfied with the procedure. Univariable and multivariable analyses revealed that bilateral graft harvesting was the only significant predictor of patient dissatisfaction (OR 2.85, p = 0.01 and OR 2.72, p = 0.02; respectively). Harvesting the oral mucosa ovoid graft from a single cheek with closure of the wound is a safe procedure with high rates of patient satisfaction.

Editorial Comment

The findings reported in the literature are disparate in regard to the morbidity associated with closure vs nonclosure of the buccal mucosal harvest site when buccal mucosa is used in urethroplasty. The types of problems that have been reported with buccal mucosal harvest are pain, salivary changes, difficulty with full opening of the mouth and peri-oral numbness. In the literature, these complications have been categorized into either short or long-term problems. Effect of Wound Closure on Buccal Mucosal Graft Harvest Site Morbidity: Results of a Randomized Prospective TrialUrologyVol. 79Issue 2PreviewTo determine the effect of closure versus nonclosure of the buccal mucosal graft harvest site in men undergoing bulbar urethroplasty in a randomized prospective study. The optimal postoperative management of the buccal mucosal graft donor site remains unknown. Full-Text PDF ReplyUrologyVol. 79Issue 2PreviewAlthough the randomized clinical trial represents the ideal method of definitively answering a clinical question, there is a relative paucity of these studies in the urological literature. The use of randomized trials in surgery has been debated, with opposing views focusing on the common limiting factors of time, cost, effort, and planning associated with performing a well-done prospective trial.1 It has also been argued that the subspecialty of reconstructive urology itself may not be amenable to randomized clinical trials because of variability in disease presentation, complex comorbid patient concerns, and the wide range of surgical techniques intrinsic to the “art” of reconstructive surgery. Full-Text PDF

Effect of Wound Closure on Buccal Mucosal Graft Harvest Site Morbidity: Results of a Randomized Prospective Trial

To determine the effect of closure versus nonclosure of the buccal mucosal graft harvest site in men undergoing bulbar urethroplasty in a randomized prospective study. The optimal postoperative management of the buccal mucosal graft donor site remains unknown. A total of 50 consecutive patients were randomized to either donor site closure or leaving the donor site open. Postoperatively, questionnaires assessing pain, diet, salivation, perioral sensation, and mouth opening were completed daily for the first week and then monthly for 6 months. The primary endpoint was postoperative oral pain. The secondary endpoints were the interval to a regular diet, perioral numbness, changes in salivation, and interval to full mouth opening. Of the 50 patients, 24 and 26 were randomized to the open and closed groups, respectively. The early postoperative pain scores demonstrated a trend favoring the nonclosure group until day 3 (4.1 vs 2.2; P=.07). At 6 months, no difference was found in the pain scores between the 2 groups (0.2 vs 0.3; P=.63). The return to a regular diet also favored the nonclosure group (70.8% vs 19.2% on day 1; P=.01) as did the return to full mouth opening (79.1% vs 15.3% on day 1; P=.001). Nonclosure resulted in less early perioral numbness (62.5% vs 92.3% on day 1; P=.008) and reduced the occurrence of bothersome numbness at 6 months (4.2% vs 23.2%; P=.05). The results of the present randomized prospective trial suggest that leaving the buccal mucosa graft harvest site open leads to lower reported early pain scores, an earlier return to a full diet, an earlier return to full mouth opening, and a decrease in bothersome perioral numbness at 6 months postoperatively.

A Randomized Prospective Trial of Primary Versus AlloDerm Closure of Buccal Mucosal Graft Harvest Site for Substitution Urethroplasty

To present a prospective, randomized trial comparing primary and AlloDerm closure of the oral harvest site. The use of buccal mucosa grafts for substitution urethroplasty is an established and durable technique. The optimal management of the buccal mucosa grafts harvest site for the intraoral defect has yet to be determined. Between February 2003 and September 2006, a total of 20 men undergoing buccal mucosal urethroplasty were randomly assigned to either primary (n = 10) or AlloDerm closure (n = 10) of the oral harvest site. All patients were clinically examined postoperatively and each completed a 10-point analog pain score and descriptive questionnaire postoperatively, at 3 weeks, and at 3, 6, and 12 months. A 100% of patients completed the study at 12 months follow-up. Oral pain dissipated acutely after 3 weeks. No significant differences in either neurosensory or mouth tightness symptoms were noted, except increased incidence of cheek swelling at 3 weeks in the AlloDerm group. AlloDerm proved to be an effective means of closing the harvest site, but offered no significant advantages when compared with primary closure. AlloDerm closure was associated with increased morbidity in mouth tightness symptoms, cheek swelling, and discomfort while chewing food; only increased incidence of cheek swelling at 3 weeks was found to be significant. Despite its excellent molecular properties and nonimmunogenic nature, the role of AlloDerm graft use in closing the buccal mucosal harvest site appears to be an unnecessary step. Primary closure was extremely well tolerated in both short- and long-term follow-up, with minimal sequelae at 12 months.

CLIMATE - A POTENTIAL CAUSE OF PRIMARY GRAFT FAILURE IN BUCCAL MUCOSAL GRAFT URETHROPLASTY

INTRODUCTION AND OBJECTIVE: The purpose of this randomized controlled trial is to determine the impact of closure versus non-closure of the buccal mucosal graft harvest site in men undergoing urethral reconstruction. The primary endpoint was postoperative oral pain. Secondary endpoints were time to return to regular diet, oral numbness, change in salivation, and time to full mouth opening. METHODS: Fifty consecutive patients have been randomized to either closure of the donor site or leaving the donor site open. All procedures were performed by one surgeon (KR). Postoperatively, questionnaires were completed daily for the first week and monthly for 6 months. The questionnaire consisted of a visual analog pain scale, as well as questions pertaining to return to regular diet, salivation, numbness, and ability to fully open mouth. Independent samples T-test and Chi-square analysis was performed on continuous and categorical data, respectively. RESULTS: Twenty-four and 26 patients were randomized to the open and closed groups. The mean ages were similar, 44 in the open and 43 in the closed group. There were no infectious or bleeding complications in either group. One patient in the closed group reported a change in denture fit post operatively. Post operative pain demonstrated a trend favoring the open group at postoperative day one (4.1 vs 2.2 p=0.07). At 6 months, there was no difference in pain scores between groups (0.2 vs 0.3 p=0.63). Return to regular diet was sooner for the open group at postoperative day one (69 vs 31 % p=0.01). At 6 months, all patients were tolerating regular diet. Numbness at harvest site was present in 62% open versus 93% closed (p=0.05) patients postoperative day one. At 6 months, 20% open vs 40% closed patients (p=0.15) reported persistent oral numbness. Salivary changes did not differ between groups at either time point. Full mouth opening at postoperative day one was reported by 77% open and 14% closed (p=0.001). At 6 months, 10% open and 8% closed reported a decrease in full mouth opening since surgery (p=0.81). CONCLUSIONS: The data from our randomized controlled trial suggest that leaving the buccal mucosa harvest site open may lead to lower reported pain scores, earlier return to full diet, and earlier return to full mouth opening. At the 6 months endpoint there may be a decrease in harvest site numbness for patients in the open group.

Closure versus nonclosure of buccal mucosal graft harvest site: A prospective randomized study on post operative morbidity

Objective:To prospectively compare the postoperative morbidity of closure versus non closure of the buccal mucosal graft (BMG) harvest site.Methods:Patients who underwent BMG harvest for urethroplasty were randomized into 2 groups; in group 1 donor site was closed and in group 2 it was left open. Self made questionnaires were used to assess post-operative pain, limitation to mouth opening, loss of sensation at graft site. The time to resumption of liquid and solid diet were also noted.Results:Fifty patients were studied, 25 in each group from July 2003 to July 2005. BMG was harvested from single cheek in most of the patients. Mean post operative pain score was 4.20 and 3.08 at day 1 in group 1 and group 2, respectively (P < 0.05). Return to oral intake in terms of liquid and solid diet was comparable between the groups. Difficulty with mouth opening was maximal during the first week with no difference among the two groups. Two patients in group 1 and one in group 2 had persistent peri-oral numbness at 6 months. None of the patients in both the groups had changes in salivation or retention cysts.Conclusion:Pain appears to be worse in the immediate post operative period with suturing of the harvest site. There is no difference in long term morbidity whether the graft site is closed or left open. It may be best to leave buccal mucosa harvest sites unsutured.