Ventral Urethrotomy Research Articles

Ventral Onlay Buccal Mucosa Graft Urethroplasty for Female Urethral Stricture: Medium-term Results in a Single Surgeon Experience

ObjectiveTo describe our own approach using buccal mucosal grafting and to assess the outcome of this approach. Materials and MethodsA total of 42 patients underwent ventral onlay BMG by a single surgeon between 2017 and 2022. A longitudinal incision along the length of the urethra was made through the anterior vaginal wall and the peri-urethral fascia was incised to create two flaps. This ventral urethrotomy ran from the meatus into the proximal health urethra above the level of the stricture.A buccal mucosal graft was harvested and sutured to the margins of the urethral mucosa itself and the flaps of peri-urethral fascia. The vaginal wall was then closed. ResultsThe mean age of the patients was 53.6 ± 12.8 years. There were no perioperative or postoperative complications. At a mean follow-up of 38.1 months, 41 patients (98%) were stricture-free. Peak flow rate improved from a mean of 7.7 ± 3.2 ml/s preoperatively to 25.9 ± 5.9 ml/s postoperatively. No patient developed incontinence. One patient developed a recurrent urethral stricture which was treated by redo urethroplasty. ConclusionsThe surgical technique applied has proved efficiency. The ventral BMG preserves the urethral sphincter and so avoids postoperative incontinence. The use of peri-urethral fascia represents a good vascular and mechanical support for the graft.

A single-stage dorsal inlay buccal mucosal graft placement through subcoronal vertical sagittal ventral urethrotomy without glansplasty for reconstruction of meatal stenosis, fossa navicularis, and distal penile urethral stricture: Our initial experience.

Reconstruction of fossa navicularis stricture (FNS) poses a challenge in providing acceptable functional and cosmetic outcomes. We describe our novel surgical technique and its short-term results. This urethroplasty technique is a single-stage dorsal inlay buccal mucosal graft placement with subcoronal vertical sagittal ventral urethrotomy without glansplasty. Twenty-one operated patients were followed up at 2 months and 6 months postoperatively. We studied the functional outcome of the International Prostate Symptom Score, quality of life (QoL) score, maximum flow rate, postvoid residual (PVR) urine, and reconstructed urethral luminal caliber. Sexual function was studied via a brief male sexual function inventory. Hypospadias objective score evaluation (HOSE) was used to assess the cosmesis. Patient satisfaction was evaluated using the global response assessment score (GRA). FNS is seen commonly associated with lichen sclerosus (n = 12). Nine patients had stricture that extended into the distal penile urethra. The mean stricture length was 2.76 cm. At the end of the study, a significant improvement in mean IPPS (18.81), mean QoL score (2.25), mean Qmax (20.94 mL/s), mean PVR (103.05 mL), and mean urethral caliber (16.06 Fr) were noted. No difference in sexual drive and erectile function but significant improvement in ejaculation was noted. All patients had single-stream urine, reconstructed urethral caliber ≥16Fr, HOSE ≥14, and GRA ≥2 at 6 months. Except for two patients, all had vertical slit-like meatus. This technique is feasible, with good cosmetic, functional, and subjective outcomes with marked patient' satisfaction.

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.

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.

Lichen sclerosis-induced long segment anterior urethral stricture: The early outcome of one-stage repair using dorsolateral onlay buccal mucosa graft.

Substitution urethroplasty using buccal mucosal grafts can be performed by several approaches including ventral onlay graft, dorsal onlay graft, or ventral urethrotomy with dorsal inlay graft. Our study aims to evaluate the surgical outcome of dorsolateral buccal mucosal graft for long segment anterior urethral stricture >6 cm in patients with Lichen sclerosus (LS). A retrospective study included patients who underwent repair for long segment anterior urethral stricture >6 cm due to LS between January 2013 and April 2019. All patients were followed-up at 3, 6, 9, and 12 months postoperatively and then yearly by clinical symptoms, uroflowmetry, and calculation of post-void residual urine volume. Retrograde urethrogram was requested for patients with voiding symptoms or decreased maximum flow rate. Stricture recurrence that required subsequent urethrotomy or urethroplasty was considered failure. The success rate and surgical complications were collected and analyzed. Thirty patients were identified. The median age (range) was 39 (25-61) years and a median (range) stricture length was 8 (6-14) cm. Most of postoperative complications were of minor degree. The success rate at median follow-up of 15 (12-24) months was 86.5%. The median maximum flow rate increased significantly from 6 (2-11) ml/s preoperatively to 18 (range: 6-23) ml/s at the 6th month (p value < 0.001). Dorsolateral buccal mucosal grafts urethroplasty for long anterior urethral stricture caused by LS has a high success rate and low risk of complications including stricture recurrence.

Novel use of Asopa technique for penile urethrocutaneous fistula repair.

To evaluate the feasibility of ventral urethrotomy, dorsal inlay (Asopa) technique in management of urethrocutaneous fistula. The Asopa technique has been employed for management of urethral stricture repair but has not been described in adult penile urethrocutaneous fistula. This is a retrospective review of IRB-approved databases of patients undergoing urethral reconstruction from two urologic reconstruction units. In this technique, the fistulous tract is circumscribed and excised, leaving a larger ventral urethral defect with healthy edges. The ventral-sagittal urethrotomy is extended, a dorsal urethrotomy made, and a graft inlaid dorsally to augment the urethral caliber prior to tension-free closure of the ventral urethrotomy. From 2010 to 2019, ten patients underwent repair of urethrocutaneous fistula using the Asopa technique. Median patient age was 33.5years (IQR 35.5). All fistulae involved penile urethra, eight had concomitant adjacent urethral stricture. Five patients failed prior hypospadias repair, three developed fistulae after surgery for penile urethral stricture, and two developed fistulae after extensive debridement (hidradenitis and Fournier's gangrene). Of these ten patients, oral mucosa graft was used in nine and preputial graft in one to augment the urethra. At median follow-up of 50.5months (IQR 26.5), 80% (8/10) of patients demonstrated durably patent urethra, with no recurrence of fistula. The Asopa technique is an established option for augmenting urethral caliber for urethral stricture disease. We demonstrate in our series that this technique can be applied to patients with urethrocutaneous fistulae.

V06-04 NEW SURGICAL TECHNIQUE: INTRAURETHRAL TUBE IN TUBE PEDICLED PREPUTIAL FLAP FOR OBLITERATIVE STRICTURES

You have accessJournal of UrologyLower-Tract Reconstruction I: Sling/ Sphincter/ Penile & Urethral Reconstruction (V06)1 Apr 2020V06-04 NEW SURGICAL TECHNIQUE: INTRAURETHRAL TUBE IN TUBE PEDICLED PREPUTIAL FLAP FOR OBLITERATIVE STRICTURES Pankaj Joshi* and Sanjay Kulkarni Pankaj Joshi*Pankaj Joshi* More articles by this author and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000885.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of Obliterative and recurrent long segment bulbar strictures is challenging. Few options exist such as double face urethroplasty or combined use of graft and flap. In majority of reported literature, the native urethra is excised and reconstruction is performed. This native urethra actually carries retrograde blood flow through bulbourethral arteries. We describe a new technique of preserving the native spongiosa and using it as cover for substitution decreasing the risk of diverticulum formation. METHODS: Ours is a tertiary care referral center for urethroplasty with experience of more than 4500 Urethroplasties in last 2 decades. This is a series of 3 patients operated between Jan 2019-March 2019.All had near Obliterative proximal bulbar stricture. Etiology was idiopathic in 1 patient and post TURP in 2 patients.2 patients had prior dorsal Onlay urethroplasties. RGU and MCU were performed. Perineal incision with ventral urethrotomy in proximal bulbar urethra was performed. The scarred urethral plate was excised. There was a gap of 3 cm between the healthy mucosal ends proximally and distally. Pedicled preputial flap was performed, transposed to perineum and tubularised over a 14 Fr Silicone catheter .The tube was anastomosed to the proximal urethral mucosa and then distally. The ventral urethrotomy which now had the spongiosa was closed over as a cover . RESULTS: Foleys catheter was kept for 6 weeks. On catheter removal, Uroflow was performed. Patients were followed up every 3 months with Uroflow, Ultrasound and urine culture .All 3 patients had good flow till last follow up.None of them developed infections.All complained of minimal post micturition dribbling. CONCLUSIONS: Obliterative redo urethral strictures merit reconstruction. Proximal post TURP strictures are not recommended to be treated with dorsal approach. Urethral substitution would require urethra transection, compromising the blood flow. This is a novel intraurethral tube in tube, flap technique which is vascular preserving and useful for management for such subset of patients. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e557-e557 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pankaj Joshi* More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement PDF downloadLoading ...

Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap

To evaluate the clinical effect of single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap. We retrospectively reviewed the clinical database of 22 male patients with penile urethral stricture who received single-stage repair using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap from November 2015 to October 2018. All the cases had no complications, such as skin fistula. The causes of stricture included iatrogenic (14/22, 63.6%), inflammation (2/22, 9.1%) and idiopathic (6/22, 27.3%). A ventral urethrotomy was made in the segment of stricture and extended proximally and distally until the normal calibre urethra was encountered. The oral mucosa graft was secured to the corpus spongiosum in dorsal onlay fashion or underlying corpora cavernosum after resection of the severe scarred urethra. Then the prepared Orandi fasciocutaneous penile skin flap was secured to edges of corpus spongiosum or oral mucosa graft. A 16 F or 14 F Foley catheter was left in situ for a minimum of 3 weeks, at which time a urethrogram was performed to look for extravasation, and the urethroscopy was performed if necessary. Success was defined as an open urethra with Qmax≥15 mL/s and no need for further surgical intervention. all the 22 patients with a mean age of 52.6 (18-73) years underwent the combined tissue-transfer technique. The mean length of the penile urethral stricture was 5.3 (2.5-10.0) cm and the mean preoperative Qmax was 6.7 mL/s. the mean length of oral mucosa grafts and fasciocutaneous skin flaps were 5.5 (3.2-10.5) cm and 6.0 (3.5-11.0) cm, respectively. The mean operation time was 225 (150-420) minutes and the mean evaluated blood loss was 53 (20.0-110.0) mL. The grafts included buccal mucosa (19/22, 86.4%) and lingual mucosa (3/22, 13.6%). The mean postoperative Q max was 21.2 (15-32) mL/s. A case of skin fistula and 2 cases of recurrent stricture were found, so the technique success rate was 81.8% (18/22) at a mean follow-up of 20.5 (5-51) months. The perioperative complications included 2 cases of infection and skin necrosis, which healed well after conservative treatment. Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap appears to be an excellent option to repair penile urethral stricture with unsalvageable urethral plate and the penile skin is available. The present clinical series showed a successful rate of 81.8% (18/22).

V12-07 RECONSTRUCTION OF A SIXTEEN-CENTIMETER ANTERIOR URETHRAL STRICTURE: DOUBLE DORSAL BUCCAL MUCOSA GRAFT WITH THE ASOPA TECHNIQUE

You have accessJournal of UrologyReconstruction1 Apr 2016V12-07 RECONSTRUCTION OF A SIXTEEN-CENTIMETER ANTERIOR URETHRAL STRICTURE: DOUBLE DORSAL BUCCAL MUCOSA GRAFT WITH THE ASOPA TECHNIQUE Alvaro Saavedra, Alejandro Rojas, Jose Arenas, Laura Velarde, and Reynaldo Gomez Alvaro SaavedraAlvaro Saavedra More articles by this author , Alejandro RojasAlejandro Rojas More articles by this author , Jose ArenasJose Arenas More articles by this author , Laura VelardeLaura Velarde More articles by this author , and Reynaldo GomezReynaldo Gomez More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2133AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Multiple surgical techniques have been described for long segment anterior urethral strictures (LSAUS), including staged urethroplasty, dorsal buccal mucosa graft (DBMG), fasciocutaneous flap, perineal urethrostomy and flap plus graft. In 2001 Asopa et al. described a new technique for dorsal graft by exposing the stricture through a ventral urethrotomy and a wide midline incision of the urethral plate to acommodate the dorsal graft. Compared to DBMG a randomized study showed significantly less blood loss and less operative time for Asopa technique with a similar 2-year success rate over 85%. Theoretically, in this approach blood supply is better preserved. In addition, it has been claimed that it is easier to learn and may provide a better visualization of the diseased urethra. The aim of this video is to provide a detailed demonstration of the Asopa technique to solve a LSAUS which required a double sequential BMG graft METHODS A 60 year-old patient with long-standing lower urinary tract symptoms presented with acute urinary retention; urethral catheterization was impossible and a suprapubic cystostomy was placed. Urethrocystoscopy and retrograde urethrogram confirmed a LSAUS, with severe spongiofibrosis. Surgical Technique: A vertical perineal incision and midline splitting of the bulbospongiosum muscle allow for wide exposure of the corpus spongiosum. Urethroscopy was used to determine the distal end of spongiofibrosis. Then, a ventral urethrotomy along penile and bulbar urethra is performed until healthy urethra is found. A deep midline dorsal urethrotomy is done dissecting urethral plate with an ophthalmic scalpel in order to accommodate a double tandem BMG affixed to the underlying corpus cavernosum with absorbable running sutures. Interrupted stitches are placed in the midline to facilitate graft take. A 16F urethral catheter is placed and standard closure by layers is performed using running sutures RESULTS Operative time was 173 minutes and blood loss was 200cc. Total stricture length was 16 cm. Patient was discharged on the 4th postoperative day with a suprapubic tube and a silicone urethral catheter. There were no postoperative complications. Pericatheter retrograde urethrogram at 3 weeks showed minimal extravasation so urethral catheter was removed. Cystostomy was left one more week and then removed. Six months after surgery his AUA-IPSS questionnaire was 5 and Qmax was 17 ml/sec CONCLUSIONS For LSAUS, the Asopa technique appears to be a reproducible, safe and effective choice to be considered in these complex cases © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1068 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Alvaro Saavedra More articles by this author Alejandro Rojas More articles by this author Jose Arenas More articles by this author Laura Velarde More articles by this author Reynaldo Gomez More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V12-01 TRANSURETHRAL VENTRAL BUCCAL MUCOSA GRAFT (BMG) INLAY URETHROPLASTY FOR DISTAL URETHRAL STRICTURES

You have accessJournal of UrologyReconstruction1 Apr 2016V12-01 TRANSURETHRAL VENTRAL BUCCAL MUCOSA GRAFT (BMG) INLAY URETHROPLASTY FOR DISTAL URETHRAL STRICTURES Mourad Abouelleil, Michael Daneshvar, and Dmitriy Nikolavsky Mourad AbouelleilMourad Abouelleil More articles by this author , Michael DaneshvarMichael Daneshvar More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2127AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Traditional options for distal urethral stricture repair involve penile skin incision to achieve access to urethra for various forms of external urethrotomy and subsequent repair with flaps or grafts. These incisions then require meticulous closure and are at risks of fistula formation, glans dehiscence and poor cosmetic outcomes. We introduce a novel surgical technique to repair fossa navicularis stricture without a need for skin incision. Our approach, a modified Naude technique, employs a ventral internal urethrotomy and precise transurethral delivery and fixation of BMG to the surface of the urethrotomy. METHODS Surgical technique: a ventral urethrotomy is performed transurethrally and a shallow wedge of the obstructive tissue is removed to achieve access to a proximal patent lumen. Appropriate size BMG is then harvested and prepared for delivery. A double arm 6-0 polydioxanone suture is used: each arm of the suture is passed through the proximal apex of the graft then through the urethra at the proximal apex of the urethrotomy and externalized through the skin. By pulling on the arms of the suture externally the graft is delivered precisely into its place in the urethra. Additional 6-0 double armed sutures are used to quilt the graft at its mid portion and their knots tied externally. The distal edge of the graft is sutured to the edge of the meatotomy with absorbable sutures. A retrospective chart review was conducted of all the patients after a fossa navicularis/ distal urethral stricture repair since March 2014 by a single surgeon (DN). Surgical and functional outcomes including complications were reviewed. Uroflow and SHIM scores were evaluated pre- and post-operatively. RESULTS This surgery was performed for 7 patients including 3 circumcised males, 2 uncircumcised males with lichen sclerosus (LS) and 2 transgender patients with neophallus. Mean patient age was 39 years (25-55), mean stricture length 2.6 cm (1-4). At a mean follow up of 8.8 month (4-18), there were no stricture recurrences, fistula, penile chordee or adverse effects on sexual function. Mean uroflow pre-op was 5.5 (0-13), post-op 22 (16-37). SHIM score pre-op 19 (23-25), post-op 23 (22-25). CONCLUSIONS We demonstrated the feasibility of incisionless distal urethral/fossa navicularis stricture repair with ventral inlay BMG. This single stage technique allows avoiding skin incision or urethral mobilization. It prevents glans dehiscence or fistula formation. It avoids the use of genital skin flaps in patients affected with LS and is a viable option for patients with distal strictures in a neophallus. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1066 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Mourad Abouelleil More articles by this author Michael Daneshvar More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Two-sided urethra-sparing reconstruction combining dorsal preputial skin plus ventral buccal mucosa grafts for tight bulbar strictures.

To report our initial experience with urethra-sparing reconstruction combining dorsal preputial skin and ventral buccal mucosa grafts for tight bulbar urethral strictures. Between November 2006 and September 2012, 26 patients with tight bulbar strictures underwent urethroplasty. Using a ventral urethrotomy approach, the two-sided urethral reconstruction was carried out avoiding the transection of urethra and augmenting the preserved urethral plate by dorsal preputial skin plus ventral buccal mucosa grafts. The primary outcome was the objective urinary result, defined as the absence of stricture recurrence. The outcome was considered a failure when any postoperative instrumentation was required. Postoperative sexual dysfunctions were investigated using a validated questionnaire. Mean follow up was 30.1 months (range 12-79 months). Mean stricture length was 3.3 cm (range 1.5-6 cm). Mean length for dorsal preputial skin and ventral buccal mucosa grafts was 3.2 cm (range 2-7 cm) and 4.9 cm (range 4-6 cm), respectively. Of 26 cases, 23 (88.5%) were successful and three (11.5%) were failures with stricture recurrence. Failures were treated with perineal urethrostomy in one case, ventral buccal graft urethroplasty in one case and internal urethrotomy in one case. Among 12 sexually active men preoperatively, none reported postoperative penile curvature/shortening, impaired erection or dissatisfaction regarding erection; sexual activity was unaltered pre- and post-surgery. In tight bulbar urethra strictures, the two-sided urethroplasty combining dorsal preputial skin and ventral buccal mucosa grafts provides a safe and effective semi-circumferential reconstruction by augmenting the preserved urethral plate, with no impact on sexual function.

A Comparative Study of Dorsal Buccal Mucosa Graft Substitution Urethroplasty by Dorsal Urethrotomy Approach versus Ventral Sagittal Urethrotomy Approach

Objectives. To compare the outcome of dorsal buccal mucosal graft (BMG) substitution urethroplasty by dorsal urethrotomy approach with ventral urethrotomy approach in management of stricture urethra. Methods and Materials. A total of 40 patients who underwent dorsal BMG substitution urethroplasty were randomized into two groups. 20 patients underwent dorsal onlay BMG urethroplasty as described by Barbagli, and the other 20 patients underwent dorsal BMG urethroplasty by ventral urethrotomy as described by Asopa. Operative time, success rate, satisfaction rate, and complications were compared between the two groups. Mean follow-up was 12 months (6–24 months). Results. Ventral urethrotomy group had considerably lesser operative time although the difference was not statistically significant. Patients in dorsal group had mean maximum flow rate of 19.6 mL/min and mean residual urine of 27 mL, whereas ventral group had a mean maximum flow rate of 18.8 and residual urine of 32 mL. Eighteen out of twenty patients voided well in each group, and postoperative imaging study in these patients showed a good lumen with no evidence of leak or extravasation. Conclusion. Though ventral sagittal urethrotomy preserves the blood supply of urethra and intraoperative time was less than dorsal urethrotomy technique, there was no statistically significant difference in final outcome using either technique.

Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts

ObjectivesTo investigate the versatility of the ventral urethrotomy approach in bulbar reconstruction with buccal mucosa (BM) grafts placed on the dorsal, ventral or dorsal plus ventral urethral surface. Patients and methodsBetween 1999 and 2008, 216 patients with bulbar strictures underwent BM graft urethroplasty using the ventral-sagittal urethrotomy approach. Of these patients, 32 (14.8%; mean stricture 3.2cm, range 1.5–5) had a dorsal graft urethroplasty (DGU), 121 (56%; mean stricture 3.7, range 1.5–8) a ventral graft urethroplasty (VGU), and 63 (29.2%; mean stricture 3.4, range 1.5–10) a dorsal plus ventral graft urethroplasty (DVGU). The strictured urethra was opened by a ventral-sagittal urethrotomy and BM graft was inserted dorsally or ventrally or dorsal plus ventral to augment the urethral plate. ResultsThe median follow-up was 37months. The overall 5-year actuarial success rate was 91.4%. The 5-year actuarial success rates were 87.8%, 95.5% and 86.3% for the DGU, VGU and DVGU, respectively. There were no statistically significant differences among the three groups. Success rates decreased significantly only with a stricture length of >4cm. ConclusionsIn BM graft bulbar urethroplasties the ventral urethrotomy access is simple and versatile, allowing an intraoperative choice of dorsal, ventral or combined dorsal and ventral grafting, with comparable success rates.

95 Critical review of a modified technique in buccal mucosa graft urethroplasty

Introduction: This presentation will be discussing the modified technique used by the author in his repair of complex urethra strictures. Barbagli et al renewed interest in buccal mucosa (BM) onlaid graft urethroplasty in early 90's. He described the technique of dorsal onlaid graft to improve the revascularisation of the free graft, to prevent shrinkage of the graft, and minimised diverticulum formation. The technique has one major drawback, namely the dorsal onlaid graft is limited to mid and distal bulbar urethra only. The author modified this original technique by employing the BM graft as a ventral onlaid graft and successfully repaired over 126 urethral strictures extending from urethral meatus to proximal bulbar urethra over the period of 1996 to 2005.Result: Using this modified ventral onlaid BM graft, mobilisation of the urethra is not necessary. This preserves the integrity of the urethral blood supply. After the stricture is identified using the Lister sound, a ventral urethrotomy is carried out. The extend of the stricture and surrounding spongiofibrosis are carefully evaluated visually as well as re‐calibration of the distal and proximal extension of the stricturing process until normal urethra is identified. 1.5 cm wide graft is then harvested with variable length depending on the extend of the stricture. All donor sites are closed primarily. Finally, the graft is sutured in situ and surrounding spongiosum is re‐deployed to provide a vascular and supporting bed for the free graft. At the penile urethra, the dartos fascia is employed to provide support to the free graft. The length of the graft ranged from 2.5 to 15 cm. The stricture sites varied extending from urethra meatus to proximal bulbar urethra just below the external sphincter. 12% recurrent stricture was reported in this group after follow up longer than 15 months. All patients had cystoscopy at 3 and 15 months to evaluate their graft calibre and recurrent stricture rate. Two out of 126 patients required complete graft revision due to sclerosing of the entire graft secondary to recurrent UTI postoperatively. Recurrent stricture tends to occur at the junctional site of the graft and usually diagnosed at their first cystoscopy. Postmicturition dribbling, UTI, ejaculatory dysfunction, erectile dysfunction, stone formation and diverticulum formation is rarely reported when compared to pedicle penile skin graft urethroplasty or pedicle scrotal graft urethroplasty. No patients have reported donor site morbidity.Conclusion: The modified ventral onlaid BM graft has proven to be a reliable graft in dealing of complex urethral stricture.