Abstract
Arab Journal of Urology (2018) 16, 211–216 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ONCOLOGY/RECONSTRUCTION ORIGINAL ARTICLE Repair of panurethral stricture: Proximal ventral and distal dorsal onlay technique of buccal mucosal graft urethroplasty Subbarao Chodisetti, Yogesh Boddepalli , Malakondareddy Kota Department of Urology, Andhra Medical College, Andhra Pradesh, India Received 27 July 2017, Received in revised form 23 October 2017, Accepted 14 November 2017 Available online 26 December 2017 KEYWORDS Abstract Objective: To report the surgical details and results of our technique of buccal mucosal graft (BMG) urethroplasty for panurethral stricture, as many studies Buccal mucosal graft have reported repair of panurethral stricture by single-stage BMG urethroplasty by urethroplasty; placing buccal mucosa ventrally, dorsally or dorsolaterally. Dorsal onlay; Patients and methods: This was an observational analysis of 38 patients with Panurethral stricture; panurethral stricture treated by placing two BMGs, one as a ventral onlay in the Stricture urethra; proximal bulbar urethra and the other as a dorsal onlay in the distal bulbar and Ventral onlay penile urethra. Success was defined as asymptomatic state with or without need for a postoperative single intervention such as dilatation or internal urethrotomy. ABBREVIATIONS Results: The 38 patients had a mean age of 44 years, with lichen sclerosus as the BMG, buccal mucosal predominant cause of stricture. The ultimate success rate was 84.2% at the end of 3 graft; months and 89.5% at the end of 1 year. Recurrent strictures appeared only in the DVIU, direct visual failed cases during the follow-up period of 11 months. None of the patients needed internal urethrotomy; redo urethroplasty during the follow-up period. LS, lichen sclerosus; Conclusions: A proximal ventral and distal dorsal onlay technique of BMG SPC, suprapubic urethroplasty is an available alternative for repairing panurethral stricture. The tech- cystostomy nique described is simple and easily reproducible with encouraging results compared to other similar techniques. 2017 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Corresponding author. E-mail address: dryogeshboddepalli@gmail.com (Y. Boddepalli). Introduction Peer review under responsibility of Arab Association of Urology. Buccal mucosal graft (BMG) urethroplasty has recently gained in popularity for urethral reconstruction. In Production and hosting by Elsevier many studies, authors have reported repair of panure- https://doi.org/10.1016/j.aju.2017.11.007 2090-598X 2017 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 212 Chodisetti et al. thral stricture by single-stage BMG urethroplasty by and the stricture is incised until normal urethra is iden- placing buccal mucosa ventrally, dorsally or dorsolater- tified. Ventral urethrotomy was performed over the ally [1]. In our technique, we place buccal mucosa ven- proximal bulbar urethra below the distal edge of the bul- trally in the proximal bulbar urethra and dorsally in bospongiosum and was extended 5 mm into the normal the distal bulbar and penile urethra. The present study urethra proximally (Fig. 1). Both distal bulbar and was conducted with the aim of reporting the surgical penile urethrae were dissected circumferentially from details and results of our technique of BMG urethro- the cavernosa by the classic Barbagli technique up to plasty for panurethral stricture. its attachment with the glans [3]. Subsequently, the dis- tal bulbar and penile urethrae were incised dorsally Patients and methods through the stricture with the proximal limit corre- sponding to the visible ventral urethral incision (Fig. 1). We placed one graft over the incised part of This was an observational analysis of 38 patients with the proximal bulbar urethra and fixed it to the edges panurethral stricture treated between August 2013 and of urethra with 4–0 polyglactin 910 (Vicryl; Ethicon August 2015. Institutional Ethics Committee approval Inc., Somerville, NJ, USA) (Fig. 2). The overlying spon- was obtained before commencing this study. All patients giosa was closed over the graft. The second graft was were treated with our technique of BMG urethroplasty placed on the dorsal aspect of the distal bulbar and during the study period. Other techniques of anterior penile urethrae. It was fixed to the edges of the incised urethroplasty were not done during this period. All the part of that urethra and tunica albuginea of the corpus data were collected according to the following inclusion cavernosa by applying several 4–0 polyglactin 910 and exclusion criteria. sutures (Fig. 3). Care should be taken to keep the muco- Inclusion criteria: sal side of both grafts towards the lumen of the urethra. All patients with panurethral stricture aged 20–65 years. The proximal end of the dorsally placed BMG over- Panurethral stricture with history of direct visual internal lapped with the distal end of the ventrally placed urethrotomy (DVIU) or dilatation. BMG by about 0.5–1 cm (Fig. 3). In the case of severe meatal stenosis, ventral meatotomy was performed until Exclusion criteria: the upper border of the graft sutured dorsally was visible (Fig. 4). The penis was repositioned in its normal anat- All cases with history of failed urethroplasty. omy and a 14-F silicone Foley passed per urethra. In all Panurethral strictures with complete or near complete oblit- cases we aimed to achieve a minimum 16-F lumen in eration of the lumen. every case at the end of surgery. Penile skin was placed back into the circumcisional position and the edges cre- ated by the ventral meatotomy were sutured to the skin. Preoperative preparation The perineal wound was closed in layers after placing a suction drain. The perineal pressure dressing was chan- Each patient was preoperatively evaluated with a his- tory, clinical examination, urine culture and sensitivity, uroflowmetry, ultrasonography of the abdomen, and a retrograde urethrogram. All patients were treated with appropriate antibiotics based on the urine culture and sensitivity perioperatively. Our technique of urethroplasty: proximal ventral and distal dorsal onlay BMG urethroplasty The patient was either nasally or orally intubated and placed in lithotomy. Two teams worked simultaneously with separate sets of instruments to avoid cross contam- ination, one harvesting oral mucosa and the other preparing the urethra for repair. Oral mucosa was har- vested from each cheek as described by Kulkarni et al. [2]. The bulbar urethra was exposed via a midline per- ineal incision. The penile urethra was exposed via a cir- cumcoronal incision with penile degloving, followed by bringing down the penis to the perineal wound. The lumen of the stricture is usually intubated with either a Fig. 1 Proximal ventral urethrotomy and distal dorsal 6-F feeding tube or with a 0.089 cm (0.035 ) guidewire, urethrotomy. Repair of panurethral stricture: Proximal ventral and distal dorsal onlay technique of buccal mucosal graft urethroplasty 213 as symptoms of poor stream requiring more than one intervention such as DVIU, dilatation or redo urethro- plasty during follow-up. Results The mean (range) age of the patients was 44 (20–65) years. The cause of stricture was lichen sclerosus (LS) in 31 (82%), idiopathic in four (11%), instrumentation in two (5%), and catheter induced in one (2%). In all, 26 of the 38 patients presented with LUTS, eight pre- sented to the emergency department with acute urinary retention and percutaneous suprapubic cystostomy (SPC) was done at that time, and four patients presented with urethrocutaneous fistula, SPC was done in all the four who proceeded with surgery after complete healing of the fistula. Two patients had a history of previous DVIU, three had urethral dilatation, and one had a his- Fig. 2 Proximal ventral onlay. tory of meatotomy (Table 1). In the early postoperative period, three patients had wound infections and one patient had penile skin necrosis. Cystourethroscopy was performed postoperatively in all patients who had LUTS at presentation, and routinely in all patients irre- spective of their symptoms at 3 months and 1 year post- operatively. During the first 3 months after surgery, re- stenosis occurred in five patients and meatal stenosis in one. The success rate was 84.2% (32/38) at the 3- month follow-up. The success rate in those aged <50 and >50 years was 85% (23/27) and 81% (9/11), respec- tively; which was not statistically significantly different (P = 1). The success rate appeared to be more in non- LS group (100%) and in patients with prior intervention (100%), but this was not statistically significant (Table 2). Meatal stenosis was treated by ventral lay open of the urethra until healthy buccal mucosa was seen dorsally. Re-stenosis was ring-shaped at the site of the overlap- ping BMG in two patients, which was treated by DVIU Fig. 3 Proximal ventral onlay and distal dorsal onlay with 3 months after the primary reconstructive surgery. One overlapping. of these patients had re-stenosis again during the follow-up period and currently carries out self- dilatation. In three patients with proximal stricture ged 48 h after surgery and the drain was removed after dilatation was performed, but they all developed recur- 2–3 days. The patient was discharged 5–7 days after sur- rent stricture during follow-up. Amongst them, two gery. The urethral catheter and the suprapubic cys- patients proceeded with perineal urethrostomy in view tostomy tube were not removed until 20 days after of advanced age, and in the other patient repeat dilata- surgery. No per catheter urethrogram was performed. tion was performed to allow him to carry out self- Cystourethroscopy was done at the end of 3 months dilatation (Fig. 5 for algorithm). Amongst the six failed and annually thereafter or whenever the patient had cases at 3 months, two were successfully treated, and symptoms of poor stream. During each follow-up visit, cystourethroscopy for them at the 1-year follow-up a careful history, examination, urine analysis, post- was normal. During the mean follow-up period of 11 void residual urine volume estimation by ultrasonogra- months, no patient was lost to follow-up. In the success phy, and cystourethroscopy were performed. group at the 1-year follow-up there were no recurrent Success was defined as an asymptomatic state with strictures. The ultimate success rate was 89.5% (34/38) normal cystourethroscopy with or without the need for at the end of 1-year after single interventions such as a postoperative single intervention such as dilatation DVIU and ventral lay open. or internal urethrotomy [4], whilst failure was defined 214 Chodisetti et al. Fig. 4 Distal ventral lay open. Table 1 Patients’ characteristics. Table 2 Success rate. Characteristic N (%) Variable Success rate, n/N (%) Failure rate, n/N (%) P Age, years Age, years 20–35 8(21.1) <50 23/27 (85.2) 4/27 (14.8) 0.79 36–50 19(50) >50 9/11 (81.8) 2/11 (18.2) 51–65 11(28.9) Cause of stricture Cause of stricture LS 25/31 (80.6) 6/31 (19.4) 0.56 LS 31(81.6) Non-LS 7/7 0/7 Instrumentation 2(5.3) Prior intervention Catheter induced 1(2.6) Yes 6/6 0/6 0.56 Idiopathic 4(10.5) No 26/32 (81.3) 6/32 (18.8) Presentation LUTS 26(68.4) Acute urinary retention 8(21.1) Urethrocutaneous fistula 4(10.5) spongiosa is frequently inadequate, the graft placed as a dorsal onlay receives better mechanical support and Prior intervention Urethral dilatation 3(7.9) blood supply from the cavernosa [6]. In addition, DVIU 2(5.3) extending the urethral incision 5 mm into the normal Ventral meatotomy 1(2.6) urethra and overlapping the proximal and distal ends No prior intervention 32(84.2) of the BMG for 0.5–1 cm may decrease the number of recurrences. In our present technique, we perform ven- tral meatotomy in all cases of meatal stenosis irrespec- Discussion tive of the available length of the BMG. Although creating a hypospadiac meatus by doing a ventral Reconstruction of panurethral strictures can be achieved meatotomy is troublesome for the patient, it may effectively in a single operation using a transperineal decrease the meatal-related complications in the long- approach with a combination of proximal ventral and term. The dorsal access to the proximal bulbar urethra distal dorsal onlay urethroplasty. In our present tech- might damage erectile function and the bulbar arteries nique, degloving the penis and bringing it to the per- [1,7]. Therefore, we are limiting this approach only for ineum with ventral urethrotomy in the proximal distal bulbar urethra, whilst for the repair of proximal bulbar urethra gives better exposure of the entire stric- bulbar stricture the ventral approach is used. The ven- ture and makes the fixation of BMG easy. In this tech- tral approach in the proximal bulbar urethra provides direct access to the urethral lumen and a clear visualisa- nique, the BMG was placed as a ventral onlay in the tion of the entire stricture during urethral opening [8]. proximal bulbar urethra, where the spongiosa is usually Therefore, the ventral onlay grafting is more effective adequate. This helps the graft to receive a better blood in the proximal bulbar urethra, where the spongiosum supply from the spongiosa [5]. On the other hand, in tissue is thick. A salvageable urethral plate of 3-mm both the distal bulbar and penile urethra, where the Repair of panurethral stricture: Proximal ventral and distal dorsal onlay technique of buccal mucosal graft urethroplasty 215 Fig. 5 Algorithm demonstrating outcomes. width is mandatory to proceed with this technique. ure of stricture disease. Kulkarni et al. [12] reported a Otherwise, all other patients should undergo a two- single-stage dorsal-onlay graft technique with one- stage repair or perineal urethrostomy. A >14-F lumen sided urethral dissection with a success rate of 86.5% is adequate to void with a normal flow rate [9].Socon- for primary urethroplasty, with most recurrent strictures sidering postoperative contraction of the BMG, our goal at the proximal end of the graft. In the Kulkarni et al. was to achieve a minimum >16-F lumen in every case at [12] technique penile invagination was done and the end of surgery. After urethroplasty recurrent stric- urethroplasty was accomplished without a hypospadiac tures are mainly narrow fibrous rings at the anastomotic meatus. In our present technique, penile degloving sites and usually due to existing pathology of the ure- appears to be unnecessary but it gives additional expo- thra, local ischaemia or defects in graft uptake [10]. sure of urethra and makes the fixation of buccal mucosa The success rate for single DVIU for these strictures easy. In our present technique, we perform two urethro- has been reported to be 35% with satisfactory outcomes tomies one in the ventrum of proximal bulbar urethra [11]. Thus, in our present study, postoperative single and the other in the dorsum of the distal bulbar and intervention was considered to treat these ring strictures penile urethrae in place of a single dorsal incision of and was included in the definition of ‘success’. The suc- the entire urethra to gain excellent visualisation of entire cess rate improved to 89.5% (34/38) at the end of 1 year extent of the stricture including the proximal extent. when including a single intervention such as DVIU and This allows fixation of the BMG proximally to the nor- ventral lay open. This improvement in success rate can mal urethra beyond the stricture to minimise proximal be explained by successful treatment of ring strictures recurrent strictures and overlapping of both the BMGs during follow-up. In the present study, all the failures minimises the likelihood of junctional strictures. (six of 38) were seen in patients with LS. But based on Although the immediate outcome of our present tech- the statistical analysis age of the patient, cause of stric- nique is favourable there is the possibility of long-term ture, or prior interventions did not predict the success attrition. To establish the favourable outcome of the or failure rate of repair (P > 0.5). Recurrent strictures present technique, these cases require longer follow-up. were seen only in the initially failed cases but not in Comparing these results with other similar studies was the success group. This was probably due to character- difficult, as there were differences in patient demograph- istics of the urethral plate and severity of stricture dis- ics, characteristics of the urethral plate, operative tech- ease encountered intraoperatively. There is always a nique, follow-up methods, and variation in the possibility that failures could appear in the success definition of success (Table 3). group with longer follow-up due to the progressive nat- 216 Chodisetti et al. Table 3 Comparison of outcomes and follow-up of panurethral urethroplasty. Reference Number Follow-up, Definition of success Success treated months rate, % Kulkarni 117 59 If the patient required no further instrumentation, including dilatation or urethrotomy 86.5 et al. [13] Singh et al. 8 19 Maximum flow rate of 15 mL/s, sterile urine, normal urethral imaging (retrograde 88 [14] urethrogram), and/or urethroscopy (with a 19-F sheath) Our 38 11 Asymptomatic state with normal cystourethroscopy with or without need for 89.5 technique postoperative single intervention such as dilatation or DVIU [5] Venkatesan K, Blakely S, Nikolavsky D. Surgical repair of bulbar Conclusions urethral strictures: advantages of ventral, dorsal, and lateral approaches and when to choose them. Adv Urol A proximal ventral and distal dorsal onlay technique of 2015;2015:397936. https://doi.org/10.1155/2015/397936. [6] Barbagli G, De Stefani S. Reconstruction of the bulbar urethra BMG urethroplasty is an available alternative for using dorsal onlay buccal mucosal grafts: New concepts and repairing panurethral strictures. Failure and disease pro- surgical tricks. Indian J Urol 2006;22:113–7. gression were more common in panurethral strictures [7] Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M. with LS. Whilst, we are routinely using this technique Current controversies in reconstructive surgery of the anterior to repair all panurethral strictures irrespective of aetiol- urethra. A clinical overview. Int Braz J Urol 2012;38:307–16. ogy, the proximal ventral and distal dorsal onlay tech- [8] Palminteri E, Berdondini E, Di Pierro GB. The advantages of the ventral approach to bulbar urethroplasty. Arab J Urol nique of BMG urethroplasty requires well-conducted 2013;11:350–4. multicentre studies with longer follow-up for further [9] Brandes SB. Lichen sclerosus: editorial comment. In: Brandes SB, acceptance. Morey AF, editors. Advanced Male Urethral and Genital Recon- structive Surgery. New Delhi: Springer (India) Private Ltd; 2016. Conflict of interest p. 45–7, second ed.. [10] Barbagli G, Guazzoni G, Palminteri E, Lazzeri M. Anastomotic fibrous ring as cause of stricture recurrence after bulbar onlay We have no conflict of interest to declare graft urethroplasty. J Urol 2006;176:614–9. [11] Brown ET, Mock S, Dmochowski R, Reynolds WS, Milam D, References Kaufman MR. Direct visual internal urethrotomy for isolated, post-urethroplasty strictures: a retrospective analysis. Ther Adv Urol 2017;9:39–44. [1] Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, [12] Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided Lazzeri M. Bulbar urethroplasty using buccal mucosa grafts anterior urethroplasty: A new dorsal onlay graft technique. BJU placed on the ventral, dorsal or lateral surface of the urethra: are Int 2009;104:1150–5. results affected by the surgical technique? J Urol 2005;174:955–7. [13] Kulkarni SB, Joshi PM, Venkatesan K. Management of [2] Kulkarni SB, Barbagli G, Sansalone S, Joshi PM. Harvesting oral panurethral stricture disease in India. J Urol 2012;188:824–30. mucosa for one-stage anterior urethroplasty. Indian J Urol [14] Singh BP, Pathak HR, Andankar MG. Dorsolateral onlay 2014;30:117–21. urethroplasty for anterior urethral strictures by a unilateral [3] Barbagli G, Morgia G, Lazzeri M. Dorsal onlay skin graft bulbar urethral mobilization approach. Indian J Urol 2009;25:211–4. urethroplasty: Long-term follow-up. Eur Urol 2008;53:628–33. [4] Blaschko SD, McAninch JW, Myers JB, Schlomer BJ, Breyer BN. Repeat urethroplasty after failed urethral reconstruction: out- come analysis of 130 patients. J Urol 2012;188:2260–4.
Journal
Arab Journal of Urology
– Taylor & Francis
Published: Jun 1, 2018
Keywords: BMG; buccal mucosal graft; DVIU; direct visual internal urethrotomy; LS; lichen sclerosus; SPC; suprapubic cystostomy; Buccal mucosal graft urethroplasty; Dorsal onlay; Panurethral stricture; Stricture urethra; Ventral onlay
