RECONSTRUCTIVE UROLOGY

Donor-site morbidity in buccal mucosa urethroplasty: lower lip or inner cheek?
Kamp S, Knoll T, Osman M, Hacker A, Michel MS, Alken P
Department of Urology, Mannheim University Hospital, Mannheim, Germany
BJU Int. 2005; 96: 619-23

• Objective: To evaluate donor-site complications of buccal mucosa urethroplasty and whether there is a difference in morbidity between harvesting the mucosa graft from the inner cheek or the lower lip.
• Patients and Methods: Twenty-four consecutive patients with recurrent urethral strictures were treated with buccal mucosa urethroplasty in our department between September 2002 and April 2004. In 12 patients the graft was harvested from the lower lip or cheek and lower lip (group 1), and in 12 patients from the cheek (group 2). The mean (range) age of patients was 51 (26-66) years in group 1 and 53 (32-75) years in group 2. The mean (range) graft length was 6.2 (2-16) cm in group 1 and 5.7 (2-13) cm in group 2. All patients were followed up using a mailed questionnaire that asked about pain, numbness, difficulties in mouth opening or ingestion, and satisfaction, monthly for the first 3 months and then every 6 months. The mean (range) follow-up was 12.5 (6-23) months.
• Results: There were no bleeding complications or disturbances in wound healing. All of the patients reported numbness in the area of the mental and buccal nerves, and graft-site tenderness after surgery. In group 1, the pain lasted for a mean (range) of 5.9 (0.5-22) months, compared to 1 (0.1-7) months in group 2 (P = 0.022). Perioral numbness lasted for a mean (range) of 10.3 (0.5-23) months in group 1 and 0.85 (0.1-3) months (P = 0.0027) in group 2. There were no statistically significant differences in problems with mouth opening or food intake between the two groups, but the patients in group 1 seemed to be less satisfied (6/12 patients satisfied) than those in group 2 (11/12 patients satisfied).
• Conclusions: Buccal mucosa graft harvesting from the lower lip and the inner cheek are both feasible, but harvesting from the lower lip resulted in a significantly greater long-term morbidity, which resulted in a lower proportion of satisfied patients. This seems to be due to a long-lasting neuropathy of the mental nerve. We therefore have changed our technique entirely from lower lip to inner cheek graft harvesting, whenever possible.
  
  
• Editorial Comment
  During the last 25 years, the buccal mucosa graft became the first choice in the field of urethral reconstructive surgery after being unused or even forgotten for over half a century prior. The buccal mucosa is probably the endothel closest to the urothelium and has been demonstrated to be the best graft for urethral reconstruction with the lowest tendency of tissue contraction.
  The presented paper investigated the morbidity on the donor side of the buccal mucosa. Two harvesting locations were compared: the inner lip vs. the inner cheek with a follow-up of up to 23 months (mean 12.5). Kamp et al. demonstrated that pain and numbness are important factors for the donor location, whereas, infection has no influence because of the disinfectant qualities of the saliva enzymes.
  In the donor location, the lower lip pain lasts 5 times longer vs. harvests from the inner cheek; the numbness lasts 10 months vs. one month for the inner cheek. In our experience, we close the wound of the inner cheek, whereas the lower lip is left open to prevent cosmetic poor results. The harvest tissue is dissected in a hexagon pattern to make a cosmetic closure of the wound possible. In addition the hexagon shaped tissue fits immediately into the recipient location without any further trimming. For the wound closure of the inner cheek, the edges are brought together to decrease possible numbness to the smallest area possible. By using inverted interrupted sutures, the patient does not feel the wound 2 weeks after surgery. The closing of the wound of the inner cheek might even pronounce the difference of lasting numbness compared to the open procedure of the lower lip.
  The harvested buccal mucosa of the inner cheek is a durable transplant for the reconstructive area. With the data presented, it is noted that the location of the inner cheek should be favored because of its significantly lower morbidity for pain and numbness. The lower lip is still available but should only be used in those cases with a long stricture. Finally, it is preferred to treat urethral stricture sufficiently early when the stricture itself is still shorter in order to have the best surgical outcome in the harvest location and the reconstructed urethra.

Dr. Karl-Dietrich Sievert, Dr. Joerg Seibold,
Dr. Axel Merseburger & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany