Dorsal Inlay Research Articles

394 - Stricture etiology, characteristics, recurrence, and patient-reported outcomes after penile one-stage dorsal inlay buccal mucosal graft urethroplasty according to Asopa

394 - Stricture etiology, characteristics, recurrence, and patient-reported outcomes after penile one-stage dorsal inlay buccal mucosal graft urethroplasty according to Asopa

Buccal One-Stage Mucosal Graft Urethroplasty for Urethral Stricture. Results of 10 Years of Experience.

Aim: Representing our data regarding use of buccal mucosa for treatment of recurrent urethral stricture. Evaluating effectiveness of buccal graft for reconstruction of urethral segment both penile and bulbar urethra.
 Materials and methods: We repaired 95 urethral strictures with buccal mucosa grafts from 2004 to 2015. Mean patient age was 39 years. The etiology of stricture was unknown in 54% of cases in other cases ischemia, trauma, instrumentation was the reason. 96% had undergone previous urethrotomy or dilation. The buccal mucosa graft was harvested from lower lip mostly. Mean graft length was 3.8 cm. The graft was placed on the ventral and dorsal bulbar urethral surface in 61 and 34 cases, respectively. In pendulous urethra we routinely use the dorsal graft the Asopa inlay graft or Barbagli onlay graft. Clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean follow-up was 36 months (range 16 to 62).
 Results: We had a success rate of 77% with dorsal inlay or onlay flap for pendulous urethra inferior than ventral graft used for bulbar urethra which was 81% success rate.
 Conclusions: In our experience the placement of buccal mucosa grafts into the ventral or dorsal surface of the bulbar urethra showed an acceptable success rates 81% and 77% respectively. Longer times of follow up is need to see if the results deteriorated more.

Urethroplasty After Urethral Urolume Stent: An International Multicenter Experience

To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume urethral stent. This is a retrospective international multicenter study on patients treated with urethral reconstruction after Urolume stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline, and posturethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure. Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14 (22.2%), dorsal onlay buccal mucosa graft (BMG) in 9 (14.3%), ventral onlay BMG in 6 (9.5%), dorsolateral onlay BMG in 9 (14.3%), ventral onlay plus dorsal inlay BMG in 3 (4.8%), augmented anastomosis in 5 (7.9%), pedicled flap urethroplasty in 6 (9.5%), 2-stage procedure in 4 (6.4%), and perineal urethrostomy in 7(11.1%). Success rate was 81% at a mean 59.7 ± 63.4 months. Dilatation or internal urethrotomy was performed in 10 (15.9%) and redo-urethroplasty in 5 (7.9%). Total International Prostate Symptom Score, quality of life, urine maximum flow, and postvoid residual significantly improved (P <.0001). Complications occurred in 8 (12.7%), all Clavien-Dindo ≤2. Disease-free survival rate after reconstruction was 88.1%, 79.5%, and 76.7% at 1, 3, and 5 years, respectively. Explant of individual strands followed by onlay BMG is the most common approach and was significantly advantageous over the other techniques (P = .018). Urethroplasty in patients with Urolume urethral stents is a viable option of reconstruction with a high success rate and very acceptable complication rate. Numerous techniques are viable; however, urethral preservation, tine-by-tine stent extraction, and use of BMG augmentation produced significantly better outcomes.

Anterior Urethroplasty Using a New Tissue Engineered Oral Mucosa Graft: Surgical Techniques and Outcomes

We investigated whether tissue engineered material may be adopted using standard techniques for anterior urethroplasty. We performed a retrospective multicenter study in patients with recurrent strictures, excluding those with failed hypospadias, lichen sclerosus, traumatic and posterior strictures. A 0.5 cm2 oral mucosa biopsy was taken from the patient cheek and sent to the laboratory to manufacture the graft. After 3 weeks the tissue engineered oral mucosal MukoCell® graft was sent to the hospital for urethroplasty. Four techniques were used, including ventral onlay, dorsal onlay, dorsal inlay and a combined technique. Cystourethrography was performed 1 month postoperatively. Patients underwent clinical evaluation, uroflowmetry and post-void residual urine measurement every 6 months. When the patient showed obstructive symptoms, defined as maximum urine flow less than 12 ml per second, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as having treatment failure. Of the 38 patients with a median age of 57 years who were included in study the strictures were penile in 3 (7.9%), bulbar in 29 (76.3%) and penobulbar in 6 (15.8%). Median stricture length was 5 cm and median followup was 55 months. Treatment succeeded in 32 of the 38 patients (84.2%) and failed in 15.8%. Success was achieved in 85.7% of ventral onlay, 83.3% of dorsal onlay, 80% of dorsal inlay and 100% of combined technique cases. No local or systemic adverse reactions due to the engineered material were noted. Our findings show that a tissue engineered oral mucosa graft can be implanted using the same techniques suggested for anterior urethroplasty and native oral mucosa, and guaranteeing a similar success rate.

Age-related changes in urinary flow following dorsal inlay graft urethroplasty for hypospadias in early childhood: Potential improvement over 11 years of age

One of the goals of hypospadias repair is to create a neourethra with normal urinary stream and normal growth. Several studies have reported that dorsal inlay graft urethroplasty (DIG) has wide indications for various clinical phenotypes of hypospadias, with good short-term outcomes and few complications. However, there have been no reports that evaluated both short-term and long-term functional outcomes using uroflowmetry in patients with DIG. The aim was to investigate whether uroflowmetry parameters change with time following DIG for hypospadias in early childhood. Uroflowmetry parameters after DIG for hypospadias in childhood were retrospectively evaluated and compared between two defined ages at follow-up: 4-6 years and 11-13 years. Maximum urinary flow (Qmax) under the 25th percentile on the Miskolc nomogram was defined as obstruction. To evaluate the shapes of uroflow quantitatively, the flow index (FI) was used. The FI cut-offs for the flow shapes were defined as tower >1.253, plateaus <0.659; bells were between these two values. Thirty-four patients met the inclusion criteria. The median operative age was 1.8 years (range 1.0-4.9 years). The median follow-up time was 10.3 years (range 7.2-12.3 years). The mean±SD Qmax at the two follow-up times increased with time, from 9.2±3.7 to 18.8±7.8. The mean±SD FI changed from 0.53±0.19 to 0.85±0.31. Both Qmax and the FI were significantly improved (p<0.001, p<0.001, respectively). There were significantly fewer patients with obstruction evaluated by the Miskolc nomogram at 11-13 years of age (n=11, 32.4%) than at 4-6 years (n=31, 91.2%) (p<0.001). Plateau shapes assessed by the FI were seen in 24 (70.6%) patients at 4-6 years and 10 (29.4%) patients at 11-13 years (Table). The number of patients with plateau shapes was significantly decreased (p=0.001). Only one report noted long-term outcomes and spontaneous uroflowmetry resolution after tubularized incised plate urethroplasty. The current report is the first to present the short-term and long-term uroflowmetry outcomes after DIG. In addition, the FI was used for the first time to evaluate uroflowmetry after hypospadias repair. It was found that the uroflowmetry parameters improved spontaneously over 11 years of age following DIG for hypospadias in early childhood. Uroflowmetry parameters improved spontaneously over 11 years of age following DIG for hypospadias in early childhood.

Сравнительный анализ одно- и двухэтапной аугментационной дорсальной INLAY-пластики буккальным графтом протяженных стриктур спонгиозной уретры

Urethral reconstructive surgery is in constant development. At present, reconstructive urethroplasty with buccal mucosa is increasingly being used. The study aimed to compare the results of a one- and two-stage augmentation urethroplasty with dorsal inlay buccal graft for strictures of the spongious urethra. The study comprised 72 patients aged 19-64 with urethral strictures 3-18 cm long. In 34 (47.2%) patients, the stricture was localized in the penile urethra, in 30 patients (41.6%) in the penile-bulbous urethra and in 8 patients (11%) in the bulbous urethra. All patients underwent augmentation urethroplasty with dorsal inlay buccal graft. The results were evaluated separately in 55 (76.4%, group 1) and 17 (23.6%, group 2) patients who underwent one-stage and two-stage surgery, respectively. The incidence rate of early postoperative complications was higher after one-stage (23.6%) compared two-stage surgery (11.8%) (p<0.05). Hematomas, wound dehiscence and urethrocutaneous fistulas were observed only after single-stage surgery. Primary healing of extensive strictures following augmentation urethroplasty with dorsal inlay buccal graft was achieved in 88.9% of patients; treatment effectiveness in the group 1 was 89.1%, in the group 2 - 88.2% (p>0.05). The final effectiveness of the operation, achieved with the use of additional surgical interventions, is estimated at 98.6%. The results of augmentation urethroplasty with dorsal inlay buccal graft do not depend on the number of stages, but fewer complications accompany two-stage surgery.

Comparative study between tubularized incised plate urethroplasty with and without dorsal inlay graft

Objectives The aim of this study was to compare the results of two single-stage hypospadias repairs, namely, tubularized incised plate (TIP) repair with and without dorsal inlay preputial skin graft urethroplasty as regards meatal stenosis, urethral stricture, and cosmetic outcome. Background The most commonly performed operation to repair distal hypospadias is the TIP repair. The key step is midline incision of the urethral plate, which widens a narrow plate and converts a flat groove into a deep plate groove, ensuring a vertical, slit neomeatus and a normal-caliber neourethra. At times in cases of distal hypospadias, the urethral plate is very narrow and needs to be augmented or substituted for further tubularization. We report our experience with primary single-stage dorsal inlay urethroplasty using inner preputial skin grafts. Patients and methods This study included 30 patients less than 10 years old who presented with primary distal types of hypospadias with narrow urethral plate at the Department of Plastic Surgery, Menoufia University Hospital and were divided into two groups: group A included 14 patients operated by TIP without dorsal inlay graft and group B included 16 patients operated by TIP with dorsal inlay graft. Patients who had undergone circumcision, previous hypospadias repair, or who had a deeply grooved urethral plate were excluded. Results A total of 16 children underwent primary dorsal inlay preputial graft urethroplasty, of whom one (6.2%) child had partial wound dehiscence, two (12.5%) of the children had meatal stenosis, and one (6.2%) of these children developed urethral stricture; 14 children underwent TIP urethroplasty, of whom two (14.3%) children had wound dehiscence, four (28.6%) of the children had meatal stenosis, and four (28.6%) of these children developed urethral stricture. Conclusion Primary dorsal inlay inner preputial graft urethroplasty successfully fulfills all traditional hypospadias repair criteria. It offers a viable, safe, rapid, and easy option in the management of proximal hypospadias with a narrow urethral plate.

Single-stage urethroplasty with buccal mucosal inlay graft for stricture caused by balanitis xerotica obliterans in boys: Outcomes in the medium term

Balanitis xerotica obliterans (BXO) is a common condition that can affect the foreskin, glans, meatus, and urethra, and rarely can also involve urethra leading to stricture. Numerous procedures have been suggested to treat urethral stricture secondary to BXO but these have had variable results. We describe the first prospective study of a single stage buccal mucosal inlay grafting in children with urethral strictures resistant to existing remedies. We treated five boys with resistant urethral strictures secondary to BXO with a single stage buccal mucosal inlay graft (BMIG, Figure). Uroflowmetry was performed both pre- and post-operatively. Functional outcome was the prime measure determining success. All the boys had a successful functional outcome and all expressed satisfaction with cosmetic outcome as well. Uroflow parameters improved remarkably, with maximum and mean urinary flow rates significantly improved from 4.2mL/s to 26mL/s (p=0.0002) and from 1.6mL/s to 12.2mL/s (p=0.003), respectively. Median follow-up was 34 months (range 30-42 months). This paper is the first to describe the successful use of buccal mucosal inlay grafts to treat refractory BXO stricture in children. Various surgical techniques have been proposed particularly in adults including single vs. staged procedures, preputial and post auricular grafts, circular mucosal buccal grafts, as well as double mucosal grafts placed both ventrally and dorsally. All of these procedures are not without problems, and had variable results and outcome. Most of the procedures have been described in adult urethra and are not suitable for paediatric small calibre urethra. Our technique of dorsal inlay graft gives a robust structure to the distal urethra avoiding diverticula, pooling or urine spraying and can be placed onto proximal urethra as well. We have not seen recurrence of BXO in our buccal grafts, which is reported in other grafts from prepuce and post auricular grafts. The number of patients presented in our study is limited, nonetheless an excellent result in all our cases makes this a compelling approach to manage BXO urethral strictures. An early intervention in such cases is paramount to convert a salvage operation to a pre-emptive procedure. A single stage buccal mucosal inlay grafting in children with BXO stricture can offer an excellent outcome.

Grafted tubularised incised plate urethroplasty: an excellent option in primary hypospadias with poor urethral plate

Background: Hypospadias represents the most frequent penile anomaly. The most challenging part of hypospadias surgery is urethral reconstruction. We here-in assess the cosmetic and functional outcome with primary single stage dorsal inlay urethroplasty using preputial skin grafts in tubularised incised-plate. We extended this indication to be the standard technique for primary hypospadias repair with poor urethral plate, flat glans and minimal ventral curvature.Methods: Children with a narrow urethral plate, shallow glans and minimal ventral curvature formed the study group. Children having severe chordee needing transection of the urethral plate,having undergone circumcision and failed hypospadias repair was excluded. This prospective study included the surgical experience of 87 cases of primary hypospadias operated upon between 2010 and 2016.Results: A straight penis was achieved in 97.7% of the patients with a 3.4% incidence of urethrocutaneous fistula. Acceptable cosmetic results were achieved in 96.5% of cases. Slit like appearance of neo urethral meatus was achieved in 96.5%, position was on the tip in 81 patients and in 6 it was mid glans. Glans dehiscence was seen in 3 patients. Meatal stenosis in 1, stricture, diverticulum and penile torsion was not seen in this series. Single and straight urinary stream was seen in 91.95%, splaying of urine in 3 patients and a thin stream in 4 patients.Conclusions: Primary dorsal inlay inner preputial graft urethroplasty successfully fulfils all traditional hypospadias repair criteria. It offers a viable option in the management of primary hypospadias with a narrow urethral plate.

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews.

Male anterior urethral stricture is scarring of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen, decreasing the urinary stream. Its surgical management is a challenging problem, and has changed dramatically in the past several decades. Open surgical repair using grafts or flaps, called substitution urethroplasty, has become the gold standard procedure for anterior urethral strictures that are not amenable to excision and primary anastomosis. Oral mucosa harvested from the inner cheek (buccal mucosa) is an ideal material, and is most commonly used for substitution urethroplasty, and lingual mucosa harvested from the underside of the tongue has recently emerged as an alternative material with equivalent outcome. Onlay augmentation of oral mucosa graft on the ventral side (ventral onlay) or dorsal side (dorsal onlay, Barbagli procedure) has been widely used for bulbar urethral stricture with comparable success rates. In bulbar urethral strictures containing obliterative or nearly obliterative segments, either a two-sided dorsal plus ventral onlay (Palminteri technique) or a combination of excision and primary anastomosis and onlay augmentation (augmented anastomotic urethroplasty) are the procedures of choice. Most penile urethral strictures can be repaired in a one-stage procedure either by dorsal inlay with ventral sagittal urethrotomy (Asopa technique) or dorsolateral onlay with one-sided urethral dissection (Kulkarni technique); however, staged urethroplasty remains the procedure of choice for complex strictures, including strictures associated with genital lichen sclerosus or failed hypospadias. This article presents an overview of substitution urethroplasty using oral mucosa graft, and reviews current topics.

FRII-15 ‘EVOLUTION OF INNOVATION’: HISTORICAL PERSPECTIVES ON THE MANAGEMENT OF URETHRAL STRICTURE DISEASE

You have accessJournal of UrologyHistory of Urology: History Forum1 Apr 2017FRII-15 ‘EVOLUTION OF INNOVATION’: HISTORICAL PERSPECTIVES ON THE MANAGEMENT OF URETHRAL STRICTURE DISEASE Devang Desai, Pankaj Joshi, Hazem Orabi, Sandesh Surana, and Sanjay Kulkarni Devang DesaiDevang Desai More articles by this author , Pankaj JoshiPankaj Joshi More articles by this author , Hazem OrabiHazem Orabi More articles by this author , Sandesh SuranaSandesh Surana More articles by this author , and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2464AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urethral stricture is a prevalent and challenging urological condition. Management has evolved over the last century, specifically with the advent of oral mucosal grafts for urethroplasty. We review the history of urethral stricture treatment. METHODS A literature search of medical texts, journal articles and historical texts was performed pertaining to history of urethral strictures. RESULTS Urethra originates from the Greek word ourein ‘urinate'. Urethral stricture was first depicted in Hindoo scriptures (6th century BC). Susruta described in Ayurveda the treatment by means of graduated dilators of metal or wood. Ambrose Pare in his depictions of urethrotomy mentions ‘A silver weir, sharp at the upper end, is to be passed in as far as the obstruction, then by oft thrusting it in and out, it may wear and make plain the resisting caruncles'. In 1894, Sapezho first used oral mucosa in urethroplasty. Humby revived the use in 1941. This landmark discovery revolutionized urethral surgery. Several modern innovations have since been described: staged repair (Johanson 1953), dorsal onlay (Barbagli 1996), ventral onlay (Morey, McAnnich 1996), dorsal inlay penile (Hayes and Malone1999), dorsal inlay bulbar (Asopa 2001), panurethral stricture management (Kulkarni 2000), nerve sparing and bulbospongiosus sparing bulbar reconstruction (Barbagli 2008), Enterourethroplasty (Mundy 2010), Non-transecting anastomotic urethroplasty (Mundy 2015). Over this period the perineal incision has evolved from a lamda to a midline incision. Current advances include liquid mucosal grafts; tissue engineering and stem cells, which would halt the process of fibrosis and prevent stricture formation. Posterior urethral injuries have traditionally been managed by anastomotic urethroplasty. Pierce 1962 performed total abdominal pubectomy. Paine & Coombs 1968 performed anastomotic urethroplasty after excision of scar by abdominal approach. 1973 Waterhouse developed abdominoperineal approach. 1976 Turner-Warwick used omental wrap for transpubic primary anastomosis. Webster & Goldwasser 1986 performed perineal anastomotic urethroplasty using inferior pubectomy. Kulkarni 2010 described etiology and management of posterior urethral injuries. Currently a progressive stepwise approach has been used for managing posterior urethral injuries. CONCLUSIONS Management of urethral stricture patients has evolved over the last century. The use of oral mucosal grafts is still one the greatest advancements. As we continue to better understand urethral strictures, we hope to make even greater strides over the next decade. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1072 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Devang Desai More articles by this author Pankaj Joshi More articles by this author Hazem Orabi More articles by this author Sandesh Surana More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V12-13 TWO-SIDED DORSAL PLUS VENTRAL ORAL GRAFT URETHROPLASTY FOR LONG ANTERIOR URETHRAL STRICTURES

You have accessJournal of UrologyReconstruction1 Apr 2016V12-13 TWO-SIDED DORSAL PLUS VENTRAL ORAL GRAFT URETHROPLASTY FOR LONG ANTERIOR URETHRAL STRICTURES Fikret Fatih Onol, Sinasi Yavuz Onol, Ahmet Bindayi, Ahmet Tahra, Eyup Veli Kücük, and Ugur Boylu Fikret Fatih OnolFikret Fatih Onol More articles by this author , Sinasi Yavuz OnolSinasi Yavuz Onol More articles by this author , Ahmet BindayiAhmet Bindayi More articles by this author , Ahmet TahraAhmet Tahra More articles by this author , Eyup Veli KücükEyup Veli Kücük More articles by this author , and Ugur BoyluUgur Boylu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2139AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Substitution urethroplasty provides good functional results in bulbar and penile urethral strictures. However, treatment of long (extending from external meatus to bulbar urethra) and tight strictures remains a challenge. One-sided (dorsal or ventral) substitution urethroplasty may not be sufficient in long strictures with a narrow urethral plate. In recent years, we have opted to use two-sided oral mucosa graft (OMG) in such cases. We describe our technique of two-sided OMG urethroplasty in long and tight strictures. METHODS Among the 83 men that underwent anterior urethroplasty in our clinic between 2010 and 2015, 23 (27.7%) had long (>80mm) or multiple strictures. Clinical evaluation included assessment of subjective symptoms with the AUA symptom score and patient-reported outcome measure for urethral stricture (USS-PROM), uroflowmetry, and combined retrograde urethrography/voiding cystourethrography. We performed two-sided urethral augmentation in patients with a tight stricture (ie. urethral caliber <5 Fr). Under lithotomy position, the entire anterior urethra was exposed through penile invagination from the midline perineal incision. OMG was first placed as ′dorsal inlay′: urethra was split along the stricture both ventrally and dorsally without mobilizing it from its bed, and the graft was secured in the dorsal urethral defect. A ′ventral onlay′ OMG was then augmented to the narrowest segment of the stricture. Foley catheter was removed after 2 to 3 weeks. Patients were followed postoperatively at 1st, 3rd, and 6th months, and annually thereafter. Cure was defined as a normal-appearing flow curve at the last postoperative visit and absence of any restenosis requiring additional intervention. RESULTS Two-sided OMG technique was used in 7 patients. Mean stricture length was 137.9±40.4 mm (range: 80 to 190 mm). With a median follow-up of 32 months (range: 6 to 58), 85.7% were cured. One patient developed recurrent stricture and underwent internal urethrotomy. Mean AUA symptom score decreased from 19.8±10.2 preoperatively to 3.2±1.6 postoperatively (p=0.02). Similarly, baseline USS-PROM LUTS score decreased from 10±4.6 to 1.5±1.4 postoperatively. Mean maximum flow rate (ml/sec) increased from 4.2±1.6 preoperatively to 28.2±10.8 postoperatively (p=0.03). CONCLUSIONS Two-sided dorsal plus ventral oral graft urethroplasty appears as an effective technique for long anterior urethral strictures. The two-sided OMG may facilitate the reconstruction of a wide-caliber urethral lumen in tight strictures. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1070 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Fikret Fatih Onol More articles by this author Sinasi Yavuz Onol More articles by this author Ahmet Bindayi More articles by this author Ahmet Tahra More articles by this author Eyup Veli Kücük More articles by this author Ugur Boylu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP52-14 NATURAL HISTORY OF PATIENTS WITH HYPOSPADIAS WHO UNDERWENT SURGICAL REPAIR: AN OBSERVATIONAL DESCRIPTIVE ANALYSIS WITH A FINAL SURPRISE

stricture was approached through perineal incision with penile invaginationto provide access to the entire length of anterior urethra in 1 stage. One sided, dorsal onlay technique was performed. Two/three oral mucosal grafts were placed dorsally. In redo cases where prior dorsal approach was used, a full-length ventral incision with dorsal inlay grafts was inserted. Postoperatively catheter was removed at 4 weeks. Follow up interval was at 3,6,9,12 months and subsequently yearly. RESULTS: Median patient age was 48.8 years, mean stricture length 14 cm and median follow-up 46 months. 184(57.75%) patients had LS and 134(42.25%) had other causes. Success rate for LS and non-LS was same 85.2%. Retention with suprapubic catheter (SPC) suggests obliterative stricture. Success rate decreased to 57.10% if patient had retention or SPC. On analysis of retention, it was seen in 60.3% patients with iatrogenic cases. Last 3 years 26 patients were referred with retention and SPC. Of this 17(65.33%.) were because iatrogenic cause The outcome was considered a success if the patient required no further instrumentation, including dilation or urethrotomy. The success rate was 89.39% for primary urethroplasty and 57.85% in patients in redo group. Most recurrent strictures developed at the proximal end of the graft. Only 3/318 patients had raised creatinine/renal failure. So raised creatinine and renal failure is less likely with panurethral stricture. CONCLUSIONS: Repair of panurethral stricture in 1 stage with 1-side dissection and dorsal onlay of oral mucosa graft is a minimally invasive technique that is simple, fast, safe, effective and reproducible by any surgeon. The incidence of iatrogenic panurethral strictures is on the rise. Iatrogenic strictures are more likely to be obliterative with early presentation.

Proximal hypospadias: A persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period

The optimal treatment of proximal hypospadias remains controversial. Several techniques have been described, but the best approach remains unsettled. To evaluate and compare the complication rates of proximal hypospadias with and without ventral curvature (VC), according to three different surgical techniques: tubularized incised plate (TIP) uretroplasty, dorsal inlay graft TIP (DIG), and staged preputial repair (SR). It was hypothesized that SR performs better than TIP and DIG for proximal hypospadias. Single-center, retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. The DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive urethral plate (UP) mobilization (UPM), dorsal plication (DP) and/or deep transverse incisions of tunica albuginea (DTITA) were selectively performed when attempting to spare transecting the UP. Division of UP and SR was favored in cases with severe VC (>50°), which was often concurrently managed with DTITA if intrinsic curvature was present. For SR, tubularization of the graft was performed 6 months later. A total of 140 patients were included. Tubularized incised plate (TIP), DIG, and SR techniques were performed in 57, 23, and 60 patients, respectively. The TIP and DIG techniques achieved similar success rates, although DIG was performed in cases of narrow and spongiosum-deficient plates. Reoperation rates with TIP and DIG techniques was 52.6% and 52.1% (NS). Urethro-cutaneous fistulas were seen in 31.5% and 13% of TIP and DIG techniques, respectively. Staged repair accomplished better results than both TIP and DIG techniques, despite being performed in the most unfavorable cases (reoperation rate 28%). After technical modifications, the DIG technique achieved similar outcomes of SR. Proximal hypospadias remains challenging, regardless of the technique utilized for its repair. Urethro-cutaneous fistulas were more commonly seen after long TIP repairs. Approximately half of the patients undergoing long TIP and DIG procedures needed re-intervention, although the percentage decreased significantly with late modifications in the DIG group. Recurrence of VC after TIP and DIG techniques seemed to be a significant and under-reported complication. Staged repairs, despite being performed for the most severe cases, resulted in overall better outcomes.

PD14-09 MOST EFFECTIVE METHOD OF USING BUCCAL GRAFT IN STAGED URETHROPLASTY FOR HYPOSPADIAS CRIPPLE.

You have accessJournal of UrologyTrauma/Reconstruction: Urethral Reconstruction (including Stricture) II1 Apr 2015PD14-09 MOST EFFECTIVE METHOD OF USING BUCCAL GRAFT IN STAGED URETHROPLASTY FOR HYPOSPADIAS CRIPPLE. Pankaj Joshi, Craig Hunter, Walid Shahrour, Sandesh Surana, Vikram shah Batra, and Sanjay Kulkarni Pankaj JoshiPankaj Joshi More articles by this author , Craig HunterCraig Hunter More articles by this author , Walid ShahrourWalid Shahrour More articles by this author , Sandesh SuranaSandesh Surana More articles by this author , Vikram shah BatraVikram shah Batra More articles by this author , and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1338AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A two-stage urethroplasty with buccal mucosa graft (BMG) is indicated for patients with history of failed hypospadias repair. Some patients have no urethral plate, severe spongiofibrosis, or complete breakdown of the urethra from failed prior interventions; they are termed hypospadias cripple. Prior to 2010, we were performing staged urethroplasty as described by Bracka, with BMG placement on the first stage. The graft was re-evaluated six months later and stage 2 tubularization was generally performed. We were not satisfied with additional staging procedures that resulted from graft contracture, scarring, and fistula formation, so we began to consider more effective methods. After 2010, we began performing a Johanson staged urethroplasty on the first stage. The second stage was a single procedure with dorsal inlay of buccal mucosa and tubularization. Our objective is to compare the success of each procedure. METHODS We retrospectively reviewed the charts from 2007 to 2013 for those who underwent staged repair for multiple failed hypospadias. In group I, from 2007 to 2010, the graft was placed on the first stage. In group II, from 2010 to 2013, the graft was placed during the second stage at time of tubularization. RESULTS Mean age of group I was 19 years (range 8-21) and of group II age 23 years (range 8-34) years. After a mean follow up of 45 months, 10 patients from group I were reviewed. After a mean follow up of 14 months, 8 patients from group II were reviewed. For Group I: 2(20%) had contraction of buccal graft requiring additional graft placement, 2(20%) patients had fistula,1(10%) patient had a urinary tract infection, 1(10%) had dehiscence, and 1(10%) had urethral stricture. Of those in group II, 1(13%) had wound infection and 1(13%) patient had fistula. Our overall complication rate was 6/10 (60%) in group I and 2/8 (25%) in group II. CONCLUSIONS Hypospadias cripple patients can be managed with staged urethroplasty with placement of BMG graft to aid a failing urethral plate. Placing the BMG during the second stage is superior to the conventional technique of BMG placement during first stage. This modification decreases patient morbidity, improves success, and results in a small, but significant paradigm shift in the management of failed hypospadias. Larger multinstitutional studies may help substantiate our experience. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e322 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pankaj Joshi More articles by this author Craig Hunter More articles by this author Walid Shahrour More articles by this author Sandesh Surana More articles by this author Vikram shah Batra More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Dorsal inlay buccal mucosal graft (Asopa) urethroplasty for anterior urethral stricture.

Asopa described the inlay of a graft into Snodgrass’s longitudinal urethral plate incision using a ventral sagittal urethrotomy approach in 2001. He claimed that this technique was easier to perform and led to less tissue ischemia due to no need for mobilization of the urethra. This approach has subsequently been popularized among reconstructive urologists as the dorsal inlay urethroplasty or Asopa technique. Depending on the location of the stricture, either a subcoronal circumferential incision is made for penile strictures, or a midline perineal incision is made for bulbar strictures. Other approaches for penile urethral strictures include the non-circumferential penile incisional approach and a penoscrotal approach. We generally prefer the circumferential degloving approach for penile urethral strictures. The penis is de-gloved and the urethra is split ventrally to exposure the stricture. It is then deepened to include the full thickness of the dorsal urethra. The dorsal surface is made raw and grafts are fixed on the urethral surface. Quilting sutures are placed to further anchor the graft. A Foley catheter is placed and the urethra is retubularized in two layers with special attention to the staggering of suture lines. The skin incision is then closed in layers. We have found that it is best to perform an Asopa urethroplasty when the urethral plate is ≥1 cm in width. The key to when to use the dorsal inlay technique all depends on the width of the urethral plate once the urethrotomy is performed, stricture etiology, and stricture location (penile vs. bulb).

V2-13 DORSAL INLAY BUCCAL MUCOSAL GRAFT (BMG) URETHROPLASTY IN THE SINGLE-STAGE MANAGEMENT OF LONG ANTERIOR URETHRAL STRICTURES

You have accessJournal of UrologyReconstruction1 Apr 2014V2-13 DORSAL INLAY BUCCAL MUCOSAL GRAFT (BMG) URETHROPLASTY IN THE SINGLE-STAGE MANAGEMENT OF LONG ANTERIOR URETHRAL STRICTURES Fikret Onol, Cem Basatac, Ahmet Tahra, Rasim Guzel, Ugur Boylu, and Sinasi Yavuz Onol Fikret OnolFikret Onol More articles by this author , Cem BasatacCem Basatac More articles by this author , Ahmet TahraAhmet Tahra More articles by this author , Rasim GuzelRasim Guzel More articles by this author , Ugur BoyluUgur Boylu More articles by this author , and Sinasi Yavuz OnolSinasi Yavuz Onol More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The management of long anterior urethral strictures (extending from the meatus to the bulbar urethra) is challenging. Selected cases with an adequate urethral plate may benefit from single-stage reconstruction. In this study, we present our technique and results of dorsal inlay BMG urethroplasty for long anterior urethral strictures. METHODS Between 2010 and 2012, 13 patients (mean age: 43.7 years) underwent dorsal inlay BMG urethroplasty for long anterior urethral strictures. All except 3 patients had a history of previous urethral dilatations and/or internal urethrotomy. The cause of stricture was lichen sclerosus in 8 and inflammatory/idiopathic in 5. Preoperative evaluation included subjective assessment of the severity of symptoms with the AUA symptom score, uroflowmetry with residual urine volume determination, combined retrograde urethrography (RU) and voiding cystourethrography (VCUG), and urethrocystoscopy by using a pediatric ureterorenoscope. Dorsal inlay BMG technique was used in all cases: the urethra was split along the stricture both ventrally and dorsally without mobilizing it from its bed, and the BMG was secured in the dorsal urethral defect. The urethra was then retubularized in one stage. Patients were followed with AUA symptom questionnaire and uroflowmetry at 3 monthly intervals in the first year and annually thereafter. Cure was defined as patient satisfaction associated with a normal-appearing flow curve at the last postoperative visit and the absence of any restenosis requiring additional intervention. RESULTS The mean stricture length was 13 cm (range: 10-15 cm) and the mean BMG length was 14.5 cm (range: 11-17 cm). The mean operation time was 170 min (130-240 min.). Average hospital stay was 2.3 days (1-7). Cure was achieved in 11 of 13 men (84.6%) during a median follow-up of 24 (range: 6-36) months. Two patients had a stricture at the proximal part of the graft and were managed by visual internal urethrotomy. Qmax values at the last follow-up were significantly improved as compared to preoperative measurements (mean 22.7±9.3 ml/s versus 6.4±5.9 ml/sec, p=0.001). The mean AUA symptom scores were also significantly improved (26.3±5.2 preoperatively vs. 6.2±2.8 postoperatively, p<0.001). CONCLUSIONS Dorsal inlay BMG urethroplasty seems as an effective method for the management of long anterior urethral strictures. In this technique, the procedure is simplified by not mobilizing or dissecting the urethra, which potentially preserves its blood supply coming from both circumflex and perforating vessels. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e361 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Fikret Onol More articles by this author Cem Basatac More articles by this author Ahmet Tahra More articles by this author Rasim Guzel More articles by this author Ugur Boylu More articles by this author Sinasi Yavuz Onol More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Dorsal inlay inner preputial graft for primary hypospadias repair.

The most commonly performed operation to repair distal hypospadias is the Tubularised incised plate (TIP) repair. The key step is midline incision of the urethral plate, which widens a narrow plate and converts a flat into a deep plate groove, ensuring a vertical, slit neomeatus and a normal-calibre neourethra. At times in cases of proximal hypospadias, the urethral plate is very narrow and needs to be augmented or substituted for further tubularisation. We report our experience with primary single stage dorsal inlay urethroplasty using preputial skin grafts. Children with proximal hypospadias with a narrow urethral plate formed the study group. Children needing transection of the urethral plate, having undergone circumcision/hypospadias repair previously or having an inadequate prepuce was excluded. Twelve children with a mean age of 48.83 months underwent primary dorsal inlay preputial graft urethroplasty for proximal hypospadias with a very narrow urethral plate. At an average follow-up of 42.16 months, 2 (16.66%) children had a breakdown of ventral shaft skin. None of the children had meatal stenosis, and none of these 12 children developed urethrocutaneous fistula. Primary dorsal inlay inner preputial graft urethroplasty successfully fulfills all traditional hypospadias repair criteria. It offers a viable, safe, rapid and easy option in the management of proximal hypospadias with a narrow urethral plate.

Dorsal onlay (Barbagli technique) versus dorsal inlay (Asopa technique) buccal mucosal graft urethroplasty for anterior urethral stricture: A prospective randomized study

To compare both the dorsal onlay technique of Barbagli and the dorsal inlay technique of Asopa for the management of long anterior urethral stricture. From January 2010 to May 2012, a total of 47 patients with long anterior urethral strictures were randomized into two groups. The first group included 25 patients who were managed by dorsal onlay buccal mucosal graft urethroplasty. The second group included 22 patients who were managed by dorsal inlay buccal mucosal graft urethroplasty. Different clinical parameters, postoperative complications and success rates were compared between both groups. The overall success rate in the dorsal onlay group was 88%, whereas in the dorsal inlay group the success rate was 86.4% during the follow-up period. The mean operative time was significantly longer in the dorsal onlay urethroplasty group (205 ± 19.63 min) than in the dorsal inlay urethroplasty group (128 ± 4.9 min, P-value <0.0001). The average blood loss was significantly higher in the dorsal onlay urethroplasty group (228 ± 5.32 mL) than in the dorsal inlay urethroplasty group (105 ± 12.05 mL, P-value <0.0001). The dorsal onlay technique of Barbagli and the dorsal inlay technique of Asopa buccal mucosal graft urethroplasty provide similar success rates. The Asopa technique is easy to carry out, provides shorter operative time and less blood loss, and it is associated with fewer complications for anterior urethral stricture repair.

Urethral compliance in hypospadias operated by tubularized incised urethral plate (TIP) with and without a dorsal inlay graft: an experimental controlled study

Abnormal uroflowmetries are common after tubularized incised plate urethroplasties (TIP), perhaps due to low compliance. We hypothesized that (1) abnormal uroflowmetries after TIP might be caused by segmental lower compliance; (2) by adding a graft to the raw area in the incised plate (TIPG), compliance might be improved by preventing secondary intention healing of the dorsal incision. A standardized penectomy was performed in 27 adult male rabbits: 9 normal non-operated controls (G1), 6 weeks after TIP (G2: n = 9) or TIPG (G3: n = 9). A standardized isolated segment (including the whole urethroplasty in G1 and G2) was progressively distended with air (1, 2 and 3 ml) in the 3 groups. The respective intraluminal pressures were measured with a tensiometer. Pressure measurements were feasible and reproducible for this model. Mean pressures tended to be higher in the experimental groups (G1: 59.7 mmHg vs. G2: 79.6 mmHg vs. G3: 100.1 mmHg for 1 ml injections; G1: 233.1 mmHg vs. G2: 241 mmHg vs. G3: 308.4 mmHg for 2 ml injections and G1: 457.3 mmHg vs. G2: 429 mmHg vs. G3: 520 mmHg for 3 ml injections) without reaching the statistical significance. In this model, the elasticity of the TIP or TIPG neourethras tended to be reduced when compared to controls. The placement of an inlay graft on the dorsal incised area did not increase the compliance. This model allows the measurement of segmental intraluminal urethral pressures generated by controlled air distension and may be a useful tool to evaluate the experimental urethroplasty models.