RECONSTRUCTIVE UROLOGY

Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: are results affected by the surgical technique?
Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M
Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy
J Urol. 2005; 174: 955-7; discussion 957-8

• Purpose: The use of buccal mucosa graft onlay urethroplasty represents the most widespread method of bulbar urethral stricture repair. The graft may be placed on the ventral or dorsal urethral surface according to surgeon experience and preference. We investigated whether the results are affected by the surgical technique by comparing the outcome of 3 types of bulbar urethroplasty using buccal mucosa graft.
• Material and Methods: We repaired 50 bulbar urethral strictures with buccal mucosa grafts from 1997 to 2002. Mean patient age was 42 years. The etiology of stricture was ischemia in 12 cases, trauma in 6, instrumentation in 4 and unknown in 28. Patients with lichen sclerosus, failed hypospadias or urethroplasty and stricture extending into the penile urethra were not included. A total of 47 patients (94%) had undergone previous urethrotomy or dilation. The buccal mucosa graft was always harvested from the cheek using a 2 team approach. Mean graft length was 4.2 cm. The graft was placed on the ventral, dorsal and lateral bulbar urethral surface in 17, 27 and 6 cases, respectively. Clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 42 months (range 12 to 76).
• Results: Of 50 cases 42 (84%) were successful and 8 (16%) failed. The 17 ventral grafts provided success in 14 cases (83%) and failure in 3 (17%). The 27 dorsal grafts provided success in 23 cases (85%) and failure in 4 (15%). The 6 lateral grafts provided success in 5 cases (83%) and failure in 1 (17%). No surgical complications were observed. Failures involved the anastomotic site (distal in 2 and proximal in 3) and the whole grafted area in 3 cases. They were treated with urethrotomy in 5 cases and 2-stage urethroplasty in 3.
• Conclusions: In our experience the placement of buccal mucosa grafts into the ventral, dorsal or lateral surface of the bulbar urethra showed the same success rates (83% to 85%) and the outcome was not affected by the surgical technique. Moreover, stricture recurrence was uniformly distributed in all patients.
  
  
• Editorial Comment
  The outcome of using a buccal mucosa onlay graft improved during recent years to over 85% in the long-term follow-up. Strictures in the area of the anastomoses still occur. It might be possible to reduce those strictures with the increased knowledge of pathology in the areas of anastomoses, which are not functional or even macroscopically visual at the time of the surgery.
  With increased knowledge of urethral anatomy, the best approach to urethral strictures makes it possible to perform reconstruction with the best outcome. It not only allows reconstruction of the lumen of the urethra, it keeps the urethra functional. Its importance of function was not understood for a long time.
  The presented data of urethral repair with a buccal mucosa onlay flap were performed in three different locations of the stricture: ventral, dorsal and lateral. The documented success rate of Barbagli et al. describes a trend for the 3 approaches but cannot be used to attribute preference to one approach or another. Despite the fact that most sacculations occurred in patients with a ventral graft, which is the most performed method, that indeed requires further explanation.
  There is an attempt to explain the urethral sacculation or post voiding dribbling with the results of the Yucel & Baskin investigations (1). The approach with innervation of the bulbospongiosous muscles might lead to the correct direction; however, other factors probably influence the sacculation as well. The buccal mucosa graft is one of the best tissues for the urethral reconstruction, but it has never been investigated as to how the urine flows through the “tube” with its physiological curbs to bring pressure towards the graft. This patch becomes a part of the “tube”-wall and the pressure that appears might weaken the graft; whereas, in a different location, it might not be influenced as strongly. This might be an explanation of the late occurrence of sacculation in the follow-up after 2 years.
  Other factors, including the 2 discussed, might influence the functional outcome. The understanding of the physiology and the physics are important in addition to prospective studies in order to perform urethral reconstruction with the highest success rate and the best functional outcome in the long term.

Reference
1. Yucel S, Baskin LS: Neuroanatomy of the male urethra and perineum. BJU Int. 2003; 92: 624-30.

Dr. Karl-Dietrich Sievert, Dr. Joerg Seibold,
Dr. Marcus Horstmann, David Schilling & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany