Dorsal Onlay Buccal Urethroplasty Research Articles

Transurethral ventral inlay buccal mucosa graft urethroplasty: technique and intermediate outcomes.

To outline our step-by-step surgical technique for a transurethral ventral buccal mucosa graft inlay urethroplasty to treat fossa navicularis and distal urethral strictures. The transurethral ventral inlay urethroplasty is accomplished in four steps. First, after obtaining proper exposure the cicatrice is excised via a transurethral ventral urethrotomy until the lumen is at least 24fr. Second, double arm 6-0 polydioxanone suture is used to deliver the triangular buccal mucosal graft to the proximal extent of the urethrotomy and secured externally. Third, the graft is secured to the meatus with 5-0 polyglactin sutures and additional 6-0 double arm polydioxanone sutures are used to quilt the graft for spread fixation. Finally, a 16fr silicone catheter is placed. Patients are discharged the same day and return for void trial after one week. A retrospective, single institution review was conducted to include all patients who underwent this procedure with a minimum of 1 year follow-up. Patients were analyzed for recurrences, and pre- and post-operative urine flow rates, post void residuals, and patient questionnaires were also reviewed. 44 patients met our inclusion criteria. Median surgical time was 120 minutes. At a mean follow up of 36 months (IQR 22-50) 95% of patients are patent without additional interventions. The 2 patients that did have stricture recurrence were found to have urethral stenosis that extended more proximally, and both were successfully treated with a dorsal onlay buccal urethroplasty. There were significant improvements in urine flow rate, post void residuals, international prostate symptom score and quality of life scores post operatively. There was no difference in post operative sexual function scores. This minimally invasive transurethral ventral urethroplasty has excellent intermediate term outcomes in terms of traditional objective measures of urethroplasty success and patient reported outcomes.

Dorsal Onlay Buccal Urethroplasty in the Female is Associated with High Quality of Life Using Validated Lower Urinary Tract Symptom Instruments

IntroductionFemale urethral stricture is rare and decreases quality of life. Buccal mucosa has become the most popular graft material for male urethroplasty but little is written about females. Rare case reports of buccal mucosa grafting in the female appear in the literature as an alternate method to more commonly performed vaginal flap urethroplasty (Blandy-style flap) or free vaginal mucosa graft urethroplasty. The hypothesis is that dorsal onlay buccal mucosa grafting will improve quality of life scores and provide acceptable recurrence-free rates. MethodsWe compiled a retrospective case series from 2009 to 2013 to identify female patients treated with dorsal onlay buccal urethroplasty via a suprameatal approach. All patients underwent pelvic exam as well as a supine stress test. Study end points included stricture recurrence verified by cystoscopy, uroflow, post-void residual urine, presence of urinary tract infection, pain, fistula formation, incontinence, and complications at the donor site and the vagina. ResultsSix patients were identified. Mean followup was 18.6 months. No stress incontinence was noted preoperatively and none developed postoperatively. No fistulas were noted. Mean stricture length was 1.2 cm and mean graft length was 2.75 cm. Two stricture recurrences (33%) were noted, requiring dilation. Mean pain score went from 7.2 to 0 on a 10-point Likert scale (p = 0.004). The number of urinary tract infections per year decreased from 4.3 to 0.3 (p = 0.038). Maximum voided velocity increased from 5.6 to 13.1 ml per second (p = 0.003) and mean post-void residual urine decreased from 270 to 34 ml (p = 0.094). No urethral or vaginal complications were reported. Two patients reported donor site morbidity but no clitoral anesthesia or pain was reported. ConclusionsDorsal onlay buccal urethroplasty provided acceptable but not improved cure rates compared with the published failure rates of alternative methods. Patients experienced significant improvements in pain, urinary flow and quality of life. It can be safely considered instead of ventral onlay vaginal flap urethroplasty or serial dilation in females with stricture.

MP76-18 A NOVEL QUANTITATIVE MEASURE OF BLADDER HYPER-SENSITIVITY IN ANALYSIS OF BLADDER DIARY WITH THE PATIENT'S SELF-REPORTED URINARY PERCEPTION GRADES

popular graft material for male urethroplasty. Buccal mucosa grafting has been described in females, but not critically evaluated. We believe this represents the largest series of female patients using buccal mucosa having undergone the dorsal onlay buccal urethroplasty (DOBU). We hypothesize that this technique will have improved recurrence free rates, no fistula formation, improved post-op incontinence rates, and no greater risk of clitoral pain compared with ventral onlay, vaginal graft techniques. METHODS: A retrospective case series was compiled from 2009-13 identifying female subjects who underwent DOBU via suprameatal approach. All patients underwent pelvic exam, as well as supine stress test. Endpoints included recurrence of stricture verified by cystoscopy, uroflow, post-void residual, presence of urinary tract infection, pain, fistula formation, incontinence, and complications from both the donor site and the vagina. RESULTS: Six subjects were identified. Mean follow up was 16.9 months. No stress incontinence was noted pre-operatively, and none developed post-op. No fistulas were noted. Mean stricture length was 1.2cm and mean graft length was 2.75cm. One stricture recurrence was noted (16%) which required dilation. Mean pain score went from 3.5/10 to 0/10 on a 10 point Likert scale (p1⁄40.075). UTIs per year went from 4.3 to 0.3 (p1⁄40.038). Maximum voided velocity increased from 5.6 to 12.65 cc/sec (p1⁄40.049), and mean post void residual decreased from 305 to 41cc (p1⁄40.099). No urethral or vaginal complications were reported, but 2 patients reported donor site morbidity. No clitoral anesthesia or pain was reported. CONCLUSIONS: DOBU is durable and compares favorably with other reported techniques to repair female urethral stricture. It can be safely considered instead of vaginal graft urethroplasty using ventral onlay for the female with urethral stricture.

Management of Urethral Stricture in Women

We describe the diagnosis and treatment of urethral strictures in women. We retrospectively identified female urethral strictures from 1998 to 2010. Study inclusion criteria were 1) clinical diagnosis of stricture, 2) stricture seen on cystoscopy, 3) urethral obstruction on videourodynamics according to the Blaivas-Groutz nomogram and/or 4) urethral caliber less than 17Fr. Postoperative recurrence was defined by the preoperative criteria. We identified 17 women with a mean age of 62 years (range 32 to 91) with stricture. Stricture was idiopathic in 8 patients, iatrogenic in 6, traumatic in 2 and associated with a urethral diverticulum in 1. Videourodynamics could not be done in 3 women due to complete obliteration of the urethra. Ten of 14 patients satisfied videourodynamic criteria for obstruction and 4 had impaired detrusor contractility. Nine women underwent vaginal flap urethroplasty, including 5 who also had a pubovaginal sling and 1 who had a Martius flap. One patient received a buccal mucosal graft as primary treatment after initial dilation. There was no recurrence at a minimum 1-year followup but 2 strictures recurred 5½ and 6 years postoperatively, respectively. These 2 women received a buccal mucosal graft and were stricture free 12 to 15 months postoperatively. Of 17 patients initially treated with urethral dilation recurrence developed in 16, requiring repeat dilations until urethroplasty was performed. In select women vaginal flap urethroplasty and buccal mucosal graft have high success rates, including 100% at 1 year and 78% at 5 years. Urethral dilation has a 6% success rate. Long-term followup is mandatory. Treatment should be individualized.

Urethrotomy Has a Much Lower Success Rate Than Previously Reported

We evaluated the success rate of direct vision internal urethrotomy as a treatment for simple male urethral strictures. A retrospective chart review was performed on 136 patients who underwent urethrotomy from January 1994 through March 2009. The Kaplan-Meier method was used to analyze stricture-free probability after the first, second, third, fourth and fifth urethrotomy. Patients with complex strictures (36) were excluded from the study for reasons including previous urethroplasty, neophallus or previous radiation, and 24 patients were lost to followup. Data were available for 76 patients. The stricture-free rate after the first urethrotomy was 8% with a median time to recurrence of 7 months. For the second urethrotomy stricture-free rate was 6% with a median time to recurrence of 9 months. For the third urethrotomy stricture-free rate was 9% with a median time to recurrence of 3 months. For procedures 4 and 5 stricture-free rate was 0% with a median time to recurrence of 20 and 8 months, respectively. Urethrotomy is a popular treatment for male urethral strictures. However, the performance characteristics are poor. Success rates were no higher than 9% in this series for first or subsequent urethrotomy during the observation period. Most of the patients in this series will be expected to experience failure with longer followup and the expected long-term success rate from any (1 through 5) urethrotomy approach is 0%. Urethrotomy should be considered a temporizing measure until definitive curative reconstruction can be planned.