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RECONSTRUCTIVE
UROLOGY
Surgical
techniques in substitution urethroplasty using buccal mucosa for the treatment
of anterior urethral strictures
Patterson JM, Chapple CR
Section of Female and Reconstructive Urology, Department of Urology, Royal
Hallamshire Hospital, Sheffield, United Kingdom
Eur Urol. 2008; 53: 1162-71
- Objectives:
Since the resurgence in the use of buccal mucosa (BM) in substitution
urethroplasty in the late 1980s and early 1990s, there has been controversy
as to which surgical technique is the most appropriate for its application.
-
Methods: The
authors performed an updated literature review. Several centres have
published widely on this topic, and the points considered include the
use BM in dorsal onlay grafts, ventral onlay grafts, and tubularised
grafts and the role of two-stage procedures.
-
Results:
In experienced hands, the outcomes of both dorsal onlay grafts and ventral
onlay grafts in bulbar urethroplasty are similar. The dorsal onlay technique
is, however, possibly less dependent on surgical expertise and therefore
more suitable for surgeons new to the practice of urethroplasty. The
complications associated with ventral onlay techniques can be minimised
by meticulous surgical technique, but in series with longer follow-up,
complications still tend to be more prevalent. In penile urethroplasty,
two-stage dorsal onlay of BM (after complete excision of the scarred
urethra) still provides the best results, although in certain circumstances
a one-stage dorsal onlay procedure is possible. In general, ventral
onlay of BM and tube graft procedures in the management of penile strictures
are associated with much higher rates of recurrence and should therefore
be avoided.
-
Conclusions:
In experienced hands the results of the ventral and dorsal onlay of
BM for bulbar urethroplasty are equivalent. Two-stage procedures are
preferable in the penile urethra, except under certain circumstances
when a one-stage dorsal onlay is feasible.
- Editorial
Comment
Since the initial reported use of buccal mucosa for urethral reconstruction
in 1894, the properties of the tissue itself have not substantially
changed despite improvements in suturing materials, instruments and
reconstructive surgical techniques (1).
Patterson and Chapple compared the most frequently used published techniques
of urethroplasty. They concluded that the technique does not seem to
be as critical for the success of the transplant as the high surgical
skills required reconstructive surgery (2). This takes into an account
the use of 5/0 or even 6/0 sutures under magnification reducing host
tissue and buccal mucosa traumatization (3). The substantial knowledge
is that buccal mucosa has good elasticity, supports neo-vascularization
because of its lamina propria, boosts the local immune status with its
increased amount of IgA, provides similarity to cytoceratin and ensures
a low risk of inflammation or scar development.
Thus, buccal mucosa with its satisfying long-term outcome is still the
golden standard against which we have to validate any new material or
approach (4).
References
1. Sievert KD, Seibold J, Schultheiss D, Feil G, Sperling H, Fisch M,
et al: [Reconstructive urology in the change, from it’s beginning
to the close future] Urologe A. 2006;45 (Suppl 4): 52-58. Article in Germany.
2. Patterson JM, Chapple CR: Surgical techniques in substitution urethroplasty
using buccal mucosa for the treatment of anterior urethral strictures.
Eur Urol. 2008; 53: 1162-71.
3. Andrich DE, Mundy AR: What is the best technique for urethroplasty?
Eur Urol. 2008, Aug 19. [Epub ahead of print]
4. Sievert KD, Amend B, Stenzl A: Tissue engineering for the lower urinary
tract: a review of a state of the art approach. Eur Urol. 2007; 52: 1580-9.
Dr.
Karl-Dietrich Sievert &
Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
E-mail: arnulf.stenzl@med.uni-tuebingen.de |