ONLAY BUCCAL MUCOSAL GRAFT URETHROPLASTY IN LONG ANTERIOR URETHRAL STRICTURE
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M. P. RAO, R. L. ACHARYA, N. GOEL, VAIBHAV SAXENA, S. TRIVEDI, U. S. DWIVEDI,
P. B. SINGH
of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi,
To assess the success of buccal mucosal graft (BMG) urethroplasty by the
dorsal onlay technique in long anterior urethral stricture (> 2 cm
long) through the midline perineal incision.
Materials and Methods: From January 1998
to December 2003, 43 patients with long anterior urethral strictures were
managed by dorsal onlay BMG urethroplasty. After voiding trial, they were
followed up at 3 months with uroflowmetry, retrograde urethrogram (RGU)
and American Urological Association symptoms score (AUA symptoms scores).
Successful outcome was defined as normal voiding with a maximum one attempt
of VIU after catheter removal. Patients were further followed-up with
uroflowmetry at 3 months interval and RGU every 6 months interval.
Results: Mean stricture length was 4.8 cm
(range 3 to 9 cm) and mean follow up was 48 months (range 12 to 84 months).
Only five patients were found to develop stricture at anastomotic site,
during follow-up. Two of them voided normally after single attempt of
VIU. Other three patients (6.9%) required further open surgery or repeat
VIU during follow up and were considered as failure.
Conclusion: Dorsal onlay BMG urethroplasty
is a simple technique with good surgical outcome.
words: urethral stricture; buccal mucosa; graft
Int Braz J Urol. 2007; 33: 181-7
treatment of urethral strictures varies according to location, length,
depth and density of the stricture. Urethral reconstruction remains a
challenge in modern urology practice. Visual internal urethrotomy (VIU)
may be useful for short annular strictures, but this procedure is associated
to a very high recurrence rate (1). Urethral reconstruction with excision
of the strictured segment and end-to-end anastomosis is successful in
more than 95% of patients with a stricture of up to 2 cm in length (2).
Patients with long strictures (> 2 cm in length) are not suitable for
end-to-end urethroplasty due to the risk of postoperative chordee formation
(3). Substitution urethroplasty is ideal for the management of long anterior
urethral strictures. The ideal material for substitution urethroplasty
remains controversial (4). Urethra is the best substitute for urethra
- Turner-Warwick’s opinion is still true (3).
Urethral substitution has long been accomplished
by using genital skin flaps, grafts of genital or extragenital tissue.
However, use of genital skin pedicle flap is a difficult procedure requiring
extensive penile and scrotal dissection to mobilize the flap to the deep
perineum, and associated to postoperative torsion and penile scarring
(5,6). Extragenital skin flap is associated to higher complication rates,
but post auricular full thickness free grafts have been associated to
better results (7). Memmelar was the first to report the use of bladder
mucosa in substitution urethroplasty, but result was discouraging due
to the problems of tissue harvesting as well as complications like urethral
exuberance and diverticula formation (8). Buccal mucosa has recently gained
its popularity as a substitute for urethral reconstruction for both strictures
and complex hypospadias (9, 10). In comparison to bladder mucosa, buccal
mucosa offers the advantages of being accustomed to a wet environment,
having good vascularity, hair less, easy to harvest, thick epithelium
making it easy to handle and less chance of graft contracture, having
a thin lamina propria allowing early inosculation, reduced rate of pseudodiverticulum
formation (4). Though Humby has described the use of buccal mucosa for
urethral substitution in 1941, it has become popular only after 1990 (11).
In our study, we describe our initial experience with dorsal buccal mucosal
graft (BMG) urethroplasty through a dorsal sagittal urethrotomy technique
for repairing long anterior urethral strictures.
January 1998 to December 2003, 43 patients with long anterior urethral
stricture were managed by single stage urethroplasty with a dorsal onlay
patch BMG. Each patient was evaluated with detailed case history, physical
examination, imaging study with retrograde urethrogram (RGU) and voiding
cystourethrogram (VCUG), uroflowmetry, AUA symptom score assessment and
other routine investigations required for anesthetic fitness. Of the strictures,
23 were idiopathic in origin, 9 were traumatic, 4 associated to lichen
sclerosus (BXO), 4 due to catheter induced trauma (iatrogenic) and 3 infective
in origin (Table-1). Mean stricture length, as measured by preoperative
RGU was 4.8 cm (range 3 to 9 cm). The sites of strictures were panurethral
in 16, penile in 9 and bulbar in 18 (Table-2). Institute Ethical committee’s
approval was taken to perform the study.
Operation was performed under general anesthesia
with nasotracheal intubation and the patient put in exaggerated lithotomy
position. Operation was done in a 2-team approach-one team engaged in
urethral procedure, and other team in harvesting the buccal mucosa. Through
a midline perineal incision, the bulbocavernosus muscle was divided exposing
the corpus spongiosum of the anterior urethra. Then the bulbar urethra
was easily dissected from corpora cavernosa. By invaginating the penis,
the penile urethra was similarly dissected up to the coronal sulcus (12).
Then the strictured segment of the urethra was identified. The other team
then harvested the buccal mucosal graft of adequate length, from the inner
cheek area below the Stensen’s duct without injuring it. Usually,
6-cm. long graft can easily be harvested from the inner cheek. If the
required graft length is more than 6 cm, then the incision line is extended
along the lower lip up to the midline to get the additional length of
buccal mucosa. In this way, buccal mucosal graft up to a length of 10-12
cm. can easily be harvested. Lignocaine (2%) with adrenaline (1:200000)
was injected into the edges of the desired graft length before harvesting
to get better hemostasis. Stay sutures are placed into the corners and
the graft is harvested. Graft donor site is closed with continuous, 3-0
chromic catgut sutures to achieve good hemostasis. The graft is then defatted
and tailored to its proper size.
The dissected urethra was rotated 180o.
The dorsal surface of the strictured segment was exposed and opened vertically
extending the incision for about 1 cm both proximally and distally into
the normal urethral lumen. The proximal and distal urethral lumina of
the urethra were calibrated. The graft was sutured, splayed and quilted
over the corpora cavernosa using few 5-0 polyglactin quilting sutures
for reinforcement with good support and minimizing the dead space. The
left margin of the urethral mucosa was sutured to the graft using 4-0
polyglactin interrupted stitches. A 16F pure silicone Foley catheter was
inserted through the urethra into the urinary bladder. Then the urethra
was rotated back to its original position and the right margin of the
urethral mucosa was sutured similarly to the remaining margin of the buccal
mucosal graft. At the end of the procedure, the graft was completely covered
by the urethra.
Suprapubic catheter is generally not used
unless the patient is already presented with it. The patient is maintained
on antibiotics until the catheter is removed.
A retrograde pericatheter contrast study
was done 3 weeks after the operation and voiding trial given. At 3 months
after catheter removal, uroflowmetry, RGU and AUA symptom score assessment
were performed. A successful outcome is defined as normal voiding with
the need for maximum one attempt of subsequent VIU. Patients were further
followed-up with uroflowmetry at 3 months and RGU every 6 months interval.
total of 43 patients (mean age 31 years, range 21 to 56 years) underwent
BMG urethroplasty by dorsal onlay graft between January 1998 and December
2003. Mean operative time was 115 min (range 105 to 160 min) and mean
follow- up 48 months (range 12 to 84 months). Only two patients required
postoperative blood transfusion. Mean duration of hospitalization was
4.5 days (range 4 to 6 days). Two patients showed extravasation of contrast
medium on retrograde contrast study after 3 weeks of operation, near the
anastomotic site (one at proximal and another one at distal anastomotic
site) and managed successfully by extended catheterization for another
2 weeks. When repeat contrast study showed no leak, voiding trial was
given. Five patients developed stricture at proximal anastomotic site
(one of them showed extravasations of contrast medium at proximal anastomotic
site on VCUG, requiring 2 weeks of extended catheterization). Two of them
voided normally after single attempt of VIU. Other three patients could
not void normally after the first attempt of VIU, though one of them voided
successfully after another VIU and other two patients required open surgery
to void successfully. These three patients (6.9%) were considered to be
failure. Two patients developed wound infection, managed successfully
with change in antibiotics as per wound swab culture sensitivity test.
No patient developed diverticulum, fistula, sacculation formation or protrusion
of the graft at external meatus. Peak urinary flow rates improved from
a mean of 8.4 ml/sec (range 4 to 11 ml/sec) preoperatively to 28.8 ml/sec.
(range 16 to 11 ml/sec) after 6 weeks post operatively (p < 0.001),
AUA symptom scores decreased from a mean
of 22.4 (range 12 to 28) preoperatively to 4.8 (range 4 to 9) after 6
weeks postoperatively (P < 0.001). In our series, minimum follow-up
was 12 months and maximum follow up was 84 months from the date of operation
anterior urethral stricture (> 2 cm long) should be treated with substitution
urethroplasty to avoid postoperative chordee formation (3). Substitution
urethroplasty may be a patch graft or tube graft (13-16). Free skin grafts
used as patch or tube graft in substitution urethroplasty are associated
with complications like graft shrinkage, diverticulum formation and recurrent
stricture, although results of patch grafts are better than tube grafts
Humby was the first to use buccal mucosa
for urethral reconstruction in a series of single stage hypospadias repair.
However, BMG urethroplasty has emerged as a popular technique in 1990s.
Whether to place the graft dorsally, ventrally or laterally is still controversial
now. Ventral onlay graft is more prone to fistula formation, sacculation
and diverticula formation leading to urinary stasis and ejaculatory dysfunction
(4). On the other hand, dorsal onlay graft procedure for the anterior
urethral stricture provides the advantages of better mechanical support
by the corporal bodies for the graft’s better take up, with less
incidence of sacculation and fistula formation (20,21). It has been reported
that dorsally placed graft can do better because of better mechanical
support for the graft and a richer vascular bed from the underlying corporal
bodies (13). In different series, ventral onlay urethroplasty has revealed
a success rate of 57.1 % to 100% with a follow-up ranging from 20 to 64
months (22-25). On the other hand, dorsal onlay BMG urethroplasty has
shown a success rate from 87.5% to 100% with a follow-up ranging from
22 to 41 months (26,27). Recently, Barbagli et al., published a retrospective
study of 50 cases with bulbar urethral stricture where buccal mucosal
graft urethroplasty were done (28). In their study, grafts were placed
as ventral, dorsal and lateral onlay in 17,27 and 6 patients respectively.
After a mean follow-up of 42 months, placement of graft into ventral,
dorsal or lateral surface of the bulbar urethra showed the similar success
rate. In our series of 43 cases, only five patients developed re-stricture
at anastomotic sites, (one of them at distal and other four at proximal
anastomotic site). Three patients developed stricture within 6 months
of operation and another two patients showed evidence of stricture on
RGU after 24 months of operation. Three of them (6.9%) were considered
as failure, because two out of 5 patients developing stricture after BMG
urethroplasty could be managed successfully with single attempt of VIU.
Our mean follow-up is also long enough (mean 48 months, range 12-84 months),
only very few series has concluded their results after such a long follow-up
Use of the AUA symptom score to assess outcomes
of urethroplasty was previously used in different series with BMG urethroplasty
for bulbar urethral reconstruction (5,30). In those series, it has already
been reported that there is an inverse relationship between the peak urinary
flow rate (Q max) and AUA symptoms scores (5). Our study similarly proved
a statistically significant difference in pre-operative and post-operative
AUA symptom scores in successful cases.
our study, it has been shown that dorsal BMG urethroplasty is a reliable
and satisfactory procedure to manage long anterior urethral strictures
with minimum complications. Harvesting the graft is simple, only requiring
good co-ordination between the two team of surgeons. Few cases, considered
as failure with stricture formation can be managed with VIU. Use of AUA
symptom score can be another tool to assess the outcome result in follow-up.
Though we have a long follow-up period, further long term follow-up should
be continued to confirm the durability of the results. The question of
placing the BMG dorsally, ventrally or laterally is still unresolved.
A randomized controlled trial with careful patient selection and long-term
evaluation of results is required to shed a light on this controversial
- Heyns CF, Steenkamp JW, De Kock ML, Whitaker P: Treatment of male
urethral strictures: is repeated dilation or internal urethrotomy useful?
J Urol. 1998; 160: 356-8.
- Webster GD, Robertson CN: The vascularized skin island urethroplasty:
its role and results in urethral stricture management. J Urol. 1985;
- Gupta NP, Ansari MS, Dogra PN, Tandon S: Dorsal buccal mucosal graft
urethroplasty by a ventral sagittal urethrotomy and minimal-access perineal
approach for anterior urethral stricture. BJU Int. 2004; 93: 1287-90.
- Bhargava S, Chapple CR: Buccal mucosal urethroplasty: is it the new
gold standard? BJU Int. 2004; 93: 1191-3.
- Morey AF, McAninch JW: When and how to use buccal mucosal grafts
in adult bulbar urethroplasty. Urology. 1996; 48: 194-8.
- Greenwell TJ, Venn SN, Mundy AR: Changing practice in anterior urethroplasty.
BJU Int. 1999; 83: 631-5.
- Webster GD, Brown MW, Koefoot RB Jr, Sihelnick S: Suboptimal results
in full thickness skin graft urethroplasty using an extrapenile skin
donor site. J Urol. 1984; 131: 1082-3.
- Memmelar J: Use of bladder mucosa in a one-stage repair of hypospadias.
J Urol. 1947; 58: 68-73.
- Ransley PG, Duffy PG, Oesch IL, Van Oyen P, Hoover D: The use of
bladder mucosa and combined bladder mucosa/preputial skin grafts for
urethral reconstruction. J Urol. 1987; 138: 1096-8.
- Baskin LS, Duckett JW: Buccal mucosa grafts in hypospadias surgery.
Br J Urol. 1995; 76 Suppl 3: 23-30.
- Humby GA: A one-stage operation for hypospadias. Br J Surg. 1941;
- Kulkarni SB, Kulkarni JS, Kirpekar DV: A new technique for urethroplasty
for balanitis xerotica obliterans. J Urol. 2000; 163: 352, V31.
- Barbagli G, Palminteri E, Rizzo M: Dorsal onlay graft urethroplasty
using penile skin or buccal mucosa in adult bulbourethral strictures.
J Urol. 1998; 160: 1307-9.
- Brannan W, Ochsner MG, Fuselier HA, Goodlet JS: Free full thickness
skin graft urethroplasty for urethral stricture: experience with 66
patients. J Urol. 1976; 115: 677-80.
- Devine PC, Fallon B, Devine CJ Jr: Free full thickness skin graft
urethroplasty. J Urol. 1976; 116: 444-6.
- Mundy AR, Stephenson TP: Pedicled preputial patch urethroplasty.
Br J Urol. 1988; 61: 48-52.
- Orandi A: One-stage urethroplasty. Br J Urol. 1968; 40: 717-9.
- Morey AF, McAninch JW: Technique of harvesting buccal mucosa for
urethral reconstruction. J Urol. 1996; 155: 1696-7.
- Venn SN, Mundy AR: Early experience with the use of buccal mucosa
for substitution urethroplasty. Br J Urol. 1998; 81: 738-40.
- Iselin CE, Webster GD: Dorsal onlay graft urethroplasty for repair
of bulbar urethral stricture. J Urol. 1999; 161: 815-8.
- Barbagli G, Selli C, Tosto A, Palminteri E: Dorsal free graft urethroplasty.
J Urol. 1996; 155: 123-6.
- Wessells H, McAninch JW: Use of free grafts in urethral stricture
reconstruction. J Urol. 1996; 155: 1912-5.
- Caldamone AA, Edstrom LE, Koyle MA, Rabinowitz R, Hulbert WC: Buccal
mucosal grafts for urethral reconstruction. Urology. 1998; 51: 15-9.
- Metro MJ, Wu HY, Snyder HM 3rd, Zderic SA, Canning DA: Buccal mucosal
grafts: lessons learned from an 8-year experience. J Urol. 2001; 166:
- Heinke T, Gerharz EW, Bonfig R, Riedmiller H: Ventral onlay urethroplasty
using buccal mucosa for complex stricture repair. Urology. 2003; 61:
- Dubey D, Kumar A, Bansal P, Srivastava A, Kapoor R, Mandhani A, et
al.: Substitution urethroplasty for anterior urethral strictures: a
critical appraisal of various techniques. BJU Int. 2003; 91: 215-8.
- Pansadoro V, Emiliozzi P, Gaffi M, Scarpone P, DePaula F, Pizzo M:
Buccal mucosa urethroplasty in the treatment of bulbar urethral strictures.
Urology. 2003; 61: 1008-10.
- Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri
M: Bulbar urethroplasty using buccal mucosa grafts placed on the ventral,
dorsal or lateral surface of the urethra: are results affected by the
surgical technique? J Urol. 2005; 174: 955-7; discussion 957-8.
- Kane CJ, Tarman GJ, Summerton DJ, Buchmann CE, Ward JF, O’Reilly
KJ, et al.: Multi-institutional experience with buccal mucosa onlay
urethroplasty for bulbar urethral reconstruction. J Urol. 2002; 167:
- Morey AF, McAninch JW, Duckett CP, Rogers RS: American Urological
Association symptom index in the assessment of urethroplasty outcomes.
J Urol. 1998; 159: 1192-4.
Accepted after revision:
October 4, 2006
Dr. Biswajit Datta
Dept. of Urology
Institute of Medical Sciences
Banaras Hindu University
Varanasi, 221005, India
this interesting article, the authors assess the success of one-stage
dorsal buccal mucosal graft for the treatment of long anterior urethral
strictures. The mean stricture length was 4.8 cm and the etiology of strictures
was idiopathic in the majority of patients. In our experience stricture
longer than 4 cm are usually due to lichen sclerosus or catheterization
during cardiovascular surgery. The idiopathic strictures, that have an
unknown etiology, are probably the result of a remote unrecognized perineal
trauma experienced during childhood (1). These strictures are located
in the bulbar urethra and are not more than 3 cm in length. The reader
will appreciate a comment on the cause of the long pan-urethral strictures
reported by the authors.
our experience, the repair of stricture longer than 4 cm using various
one-stage bulbar urethroplasties showed a higher failure rate when compared
to shorter strictures. The use of two-stage urethroplasty should be preferred
in patients with pan-urethral diseases, often associate with local adverse
condition such as lichen sclerosus. The authors, however, should be praised
for having treated these complex cases using a one-stage urethroplasty
thus avoiding to the patient the discomfort of perineal urinary diversion
that many time is not accepted by the patient for religious, hygienic,
cultural or psychological reasons.
et collaborators suggested that substitution urethroplasty steadily deteriorated
with time, so that by 15 years more that half of the patients required
evaluation for stricture recurrence (2).
series of original dorsal skin onlay graft urethroplasty using penile
skin showed a steadily deterioration over time of success rate at the
interim follow-up (3) and the deterioration rate is more evident at the
long-term follow-up (data available on-line at the website: www.urethracenter.it).
Surprisingly, in this series of patients, with follow-up longer than 5
years, the recurrence rate is very low and the recurrence were located
in the proximal part and not in the distal-penile tract, were the thin
spongiosum tissue should not assure an adequate vascular support to the
graft. Probably, this is due to the fact that the authors have used a
dorsal onlay, thus preserving the urethral plate as vascular support to
the graft. Five patients developed stricture at the proximal anastomotic
site and this is a typical feature of stricture recurrence after any substitution
urethroplasty (4). It will be interesting to know if were there risk factors
(i.e. smoke) or medical problems that should be taken into account (i.e.
Diabetes) in patients with stricture recurrence.
it will be interesting for the readers to known why the authors suggested
the use of exaggerated lithotomy position for strictures located in the
penile and bulbar urethra, not involving the posterior tract and why two
patients require postoperative blood transfusion for penile or bulbar
question of placing the buccal mucosal graft dorsally, laterally or ventrally
is not a controversial issue. Surgical treatment of urethral stricture
diseases is a continually evolving process, and the superiority of one
technique over another has yet to be clearly defined. The urologist must
be familiar with the use of various surgical techniques to deal with any
condition of the urethra during surgery, as no one technique is appropriate
for all stricture diseases (5). Reconstructive urologists are, however,
aware that several cautionary details to be considered when evaluating,
interpreting, or performing urethral surgery. They include the history
of urethral stricture disease (etiology and previous therapies), choice
of appropriate procedure, length of the stenosis, homogeneous population,
economic issues, age of patient, the surgical techniques and methods of
outcome assessment (success/failure). Thus, many of us are disputing formally
and systematically how to find an appropriate response to these issues
and how to provide long-term follow-up.
- Waxman SW, Morey AF: Management of urethral strictures. Lancet 2006;
- Andrich DE, Dunglison N, Greenwell TJ, Mundy AR: The long-term results
of urethroplasty. J Urol. 2003; 170: 90-92.
- Barbagli G, Palminteri E, Lazzeri M, Turini D: Interim outcomes of
dorsal skin graft bulbar urethroplasty. J Urol. 2004; 172: 1365-7.
- Barbagli G, Guazzoni G, Palminteri E, Lazzeri M: Anastomotic fibrous
ring as cause of stricture recurrence after bulbar onlay graft urethroplasty.
J Urol. 2006; 176: 614-9.
- Peterson AC, Webster GD: Management of urethral stricture disease:
developing options for surgical intervention. BJU Int. 2004; 94: 971-6.
Dr. Guido Barbagli
Center for Urethral Reconstructive Surgery