RECONSTRUCTIVE UROLOGY

Multi-institutional experience with buccal mucosa onlay urethroplasty for bulbar urethral reconstruction
Kane CJ, Tarman GJ, Summerton DJ, Buchmann CE, Ward JF, O’Reilly KJ, Ruiz H, Thrasher JB, Zorn B, Smith C, Morey AF
From the Departments of Urology and Oral and Maxillofacial Surgery, Naval Medical Center, San Diego, San Diego, California, Department of Surgery, Urology Service, Madigan Army Medical Center, Tacoma, Washington, Department of Surgery, Urology Service, Brooke Army Medical Center, San Antonio, Texas, and Department of Surgery, Urology Service, Walter Reed Army Medical Center, Washington, DC, USA
J Urol. 2002; 167:1314-7

• Purpose: Buccal mucosa has been advocated as an ideal graft material for urethral reconstruction. We report our multicenter experience with buccal mucosa ventral onlay urethroplasty for complex bulbar urethral reconstruction in adults.
• Materials and Methods: A retrospective analysis of patients who had undergone buccal onlay urethroplasty at 4 military medical treatment facilities participating in the Uniformed Services Urology Research Group was performed. The database generated included demographic data, genitourinary history, preoperative symptoms (American Urological Association symptom score), preoperative urinary flow rate, stricture length and operative statistics. Postoperative followup data included symptom score, flow rate, retrograde urethrogram results, and complications.
• Results: A total of 53 patients (average age 32 years, range 17 to 64) underwent buccal mucosa graft urethroplasty between January, 1996 and March, 1998 for refractory strictures. Sixteen patients had undergone an average of 2.2 prior endoscopic procedures (range 1 to 7). Average stricture length was 3.6 plus or minus standard deviation 1.8 cm. (range 2 to 7.5) as measured on preoperative retrograde urethrogram. Followup averaged 25 months (range 11 to 40 months). Average symptom scores decreased from 21.2 (range 14 to 33) preoperatively to 5.4 (range 3 to 8) postoperatively (p<0.001). Average peak urinary flow rates increased from 7.9 preoperatively to 30.1 ml. per second postoperatively (p<0.001). Postoperative retrograde urethrograms were available for 34 patients and were normal in 24. The overall complication rate was 5.4%. Three patients required endoscopic incisions. One patient has a recurrent narrowing and treatment is considered a failure. There were 4 sacculations (7.5%) and 6 narrowings, 3 of which required further treatment. Of the patients 50 required no additional procedures (94.3%).
• Conclusions: Buccal mucosa grafts used as a ventral onlay for bulbar urethral reconstruction yield reproducibly excellent results with minimal morbidity and low complication rates. Longer followup will be required to confirm the durability of our results.
  
  
• Editorial Comment
  In this multi-institutional study the results of 53 patients who underwent buccal mucosa craft urethroplasty in complicated stricture disease were studied. The minimum follow-up in these patients was close to 1 year. The results were respectable. Eleven percent of the patients had some form of recurrent stricture, but only half of them (6%) needed further treatment leading to a success rate of 94%. The fact that there were several surgeons and centers involved, that the means success rate is probably not due to the unpublished expertise of a single surgeon but rather due to other factors common to all centers involved, such as ventral onlay of the buccal mucosa, meticulous harvesting and preparation, careful suturing technique and maybe even the short hospital stay of the patients. The excellent results of this study confirm the biological properties of the oral cavity epithelium as a viable option for urethral reconstruction which will be with us at least in the near future.

Dr. Arnulf Stenzl
Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany