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Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts

Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus... Arab Journal of Urology (2012) 10, 118–124 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ONCOLOGY/RECONSTRUCTION ORIGINAL ARTICLE Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts a, a b c Enzo Palminteri , Elisa Berdondini , Ferdinando Fusco , Cosimo De Nunzio , d e Kostas Giannitsas , Ahmed A. Shokeir Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy Department of Urology, University Federico II, Naples, Italy Department of Urology, Sant’Andrea Hospital, ‘La Sapienza’ University, Rome, Italy Urology Department, Patras University Hospital, Patras, Greece Urology & Nephrology Center, Mansoura, Egypt Received 12 January 2012, Received in revised form 24 February 2012, Accepted 25 February 2012 Available online 20 April 2012 KEYWORDS Abstract Objectives: To investigate the versatility of the ventral urethrotomy approach in bulbar reconstruction with buccal mucosa (BM) grafts placed on the Urethra; dorsal, ventral or dorsal plus ventral urethral surface. Stricture; Patients and methods: Between 1999 and 2008, 216 patients with bulbar strictures Urethroplasty; underwent BM graft urethroplasty using the ventral-sagittal urethrotomy approach. Buccal mucosa; Of these patients, 32 (14.8%; mean stricture 3.2 cm, range 1.5–5) had a dorsal graft Graft urethroplasty (DGU), 121 (56%; mean stricture 3.7, range 1.5–8) a ventral graft ure- throplasty (VGU), and 63 (29.2%; mean stricture 3.4, range 1.5–10) a dorsal plus ABBREVIATIONS ventral graft urethroplasty (DVGU). The strictured urethra was opened by a ven- AU, anastomotic ure- tral-sagittal urethrotomy and BM graft was inserted dorsally or ventrally or dorsal throplasty; BM, buccal plus ventral to augment the urethral plate. mucosa; Results: The median follow-up was 37 months. The overall 5-year actuarial suc- (D)(V)(DV)GU, (dor- cess rate was 91.4%. The 5-year actuarial success rates were 87.8%, 95.5% and sal) (ventral) (dorsal Corresponding author. Address: Centre for Urethral and Genitalia Reconstructive Surgery, Via Fra’ Guittone 2, 52100 Arezzo, Italy. Tel.: +39 3357012783; fax: +39 057527056. E-mail address: enzo.palminteri@inwind.it (E. Palminteri). 2090-598X ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Production and hosting by Elsevier Peer review under responsibility of Arab Association of Urology. http://dx.doi.org/10.1016/j.aju.2012.02.009 Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts 119 plus ventral) graft ure- 86.3% for the DGU, VGU and DVGU, respectively. There were no statistically sig- throplasty; VCUG, nificant differences among the three groups. Success rates decreased significantly voiding cysto- only with a stricture length of >4 cm. urethrography Conclusions: In BM graft bulbar urethroplasties the ventral urethrotomy access is simple and versatile, allowing an intraoperative choice of dorsal, ventral or com- bined dorsal and ventral grafting, with comparable success rates. ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction when the dissection from the corpora needs to be very proximal [6,7]. The dorsal urethral mobilisation was shown to be difficult in scarred urethras with marked Buccal mucosa (BM) is considered the reference stan- periurethral fibrosis after previous treatments [8]; even dard urethral substitute in graft bulbar urethroplasties, an extensive dorsal approach could cause urethral and its dorsal or ventral placement using the dorsal or ischaemia. Therefore, in 2001, Asopa et al. [8] described ventral urethrotomy approaches has become a conten- a different dorsal graft using a ventral urethrotomy ap- tious issue, with no resolution to date [1,2]. proach, stating that the procedure is easier because the In 1953, Presman and Greenfield [3] introduced ven- urethra is not mobilised. Recently, Kulkarni et al. [9] tral grafting by a ventral urethrotomy, which gives easy elaborated a modified dorso-lateral approach which pre- access to the urethra and good visualisation of the stric- serves one lateral vascular supply to the urethra. In ture. In 1996, this technique was revived by Morey and 2008, we described, for the first time, the combined dor- McAninch [4]. sal plus ventral double graft for repairing very tight bul- In 1996, Barbagli et al. [5] introduced the novelty of bar strictures [10]. dorsal grafting by a dorsal urethrotomy. Nevertheless, To investigate the feasibility, efficacy and versatility the same authors recognised that the dorsal approach of the ventral approach, in the present study we retro- is simpler in the distal bulbar urethra, whereas the ven- spectively evaluated and statistically analysed outcomes tral approach with ventral grafting is more effective in in 216 patients who underwent graft bulbar urethro- the proximal bulbar urethra, where the spongiosum tis- plasty using a ventral urethrotomy access, and with sue is thick [6]. Also they advised that dorsal access the BM placed on the dorsal, ventral or dorsal plus might damage erectile function and the bulbar arteries Table 1 Patients and stricture characteristics in the three study groups. Variable DGU VGU DVGU No. patients 32 121 63 Age (years), Mean ± (SD) 39.2 (16.2) 39.2 (13.3) 39.0 (14.3) Cause of stricture, n Unknown 19 83 41 Catheter 6 27 17 Instrumentation 4 8 2 Trauma 3 3 2 Infection 0 0 1 Previous treatment, n (%) 23 (71.9) 84 (69.4) 43 (68.2) Dilatations 20 26 16 Urethrotomy 19 80 42 Urethroplasty 4 10 2 None 9 37 20 Mean (SD) Stricture length (cm) 3.2 (1.1) 3.7 (1.2) 3.4 (1.4) Range 1.5–5 1.5–8 1.5–10 Stricture length (cm), n 1.5–2 10 11 9 >2–4 17 85 48 >4–6 5 21 4 >6 0 4 2 Median (range) follow-up (months) 43 (12–107) 27 (12–113) 49 (12–85) One patient may receive more than one treatment. 120 Palminteri et al. ventral surface of the urethra. We also analysed the risk thral plate, it is easy to expose the corpora. A ventral factors that could affect the success rate over a median graft was preferred in strictures located in the proximal follow-up of 37 months, using both bivariable and mul- bulbar urethra where it is difficult to work dorsally and tivariable analyses. the split of the corpora causes a lack of adequate sup- port for the graft; furthermore, the abundant ventral Patients and methods spongiosum provides adequate vascularisation and sup- port for the graft [4]. Finally, the dorsal plus ventral Patients double graft was used in tight strictures with a narrow residual urethral plate (<5 mm) in which a single patch seemed to be insufficient to make a sufficiently wide We reviewed the charts of patients with bulbar urethral lumen. strictures who underwent BM graft bulbar urethroplasty Baseline patient and stricture characteristics are by a ventral-sagittal urethrotomy approach. The study shown in Table 1. The preoperative evaluation included included 216 consecutive patients who were treated be- a clinical history, physical examination, oral cavity tween 1999 and 2008 and had completed a minimum fol- examination, urine culture, uroflowmetry, retrograde low-up of 12 months. None of the patients was lost to and voiding cysto-urethrography (VCUG) and ure- follow-up. Patients with lichen sclerosis and failed hypo- throscopy. All patients were informed of the rare post- spadias repair were excluded. The study population was operative complications at the oral donor site. divided into three groups according to the location of the BM graft: dorsal, ventral or combined dorsal and Surgical technique ventral. The techniques were selected according to the site and All surgical procedures were carried out by the same length of the stricture within the bulbar urethra, and urologist (E.P.). Through an inverted-Y incision the according to the quality of the urethral plate. Generally, bulbocavernous muscles were divided, exposing the bul- we used the dorsal graft in strictures located in the distal bar urethra. The strictured tract was opened by the or middle bulbar urethra where, after incising the ure- Figure 1 Diagram illustrating DGU, VGU, and DVGU, using a ventral-sagittal urethrotomy approach. Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts 121 ventral-sagittal urethrotomy approach, exposing the Dorsal plus ventral graft urethroplasty (DVGU) urethral plate, and then the BM patch graft was inserted The exposed dorsal urethral plate was incised in the dorsally, ventrally or dorsally ventrally to augment the midline to create an elliptical area where the first dor- urethra (Fig. 1). Of 216 urethroplasties, the graft was sal-inlay graft was placed to augment the urethra dor- placed on the dorsal urethral surface using the technique sally. Subsequently, the second ventral-onlay graft was of Asopa et al. in 32 (14.8%) cases, on the ventral sur- sutured to the lateral urethral margins to complete ven- face in 121 (56%) and on the dorsal plus ventral surface trally the augmented urethroplasty by preserving the by our previously described technique [10] in 63 urethral plate. Finally, the spongiosum was closed over (29.2%). the graft [10]. Dorsal graft urethroplasty (DGU) Harvesting of BM The exposed dorsal urethral plate was incised in the The BM was harvested from the cheek. Of 153 DGUs midline down to the tunica albuginea. The margins of and VGUs, the BM was harvested from the right cheek the incised dorsal urethra were dissected from the tunica in 152 patients and from both cheeks in one. Of 63 without lifting the two halves of the bisected urethra. An DVGUs, 58 patients had a wide single graft harvested elliptical raw area was created over the tunica where the from one cheek and subsequently tailored into two graft was placed and sutured. A catheter was inserted smaller grafts, according to the length of the dorsal and the lateral margins of the augmented urethral plate and ventral urethral openings, while in four patients were sutured together with a running suture. Finally the the two grafts were harvested bilaterally from both adventitia of the spongiosum was closed [8]. cheeks. The mean (SD, range) length of the harvested BM graft was 6 (0.36, 5–8) cm and the width was 1.7 Ventral graft urethroplasty (VGU) (0.38, 1–2.5) cm. The graft was sutured to the mucosal margins of the ex- A suction drain was left in place for 2 days. An 18-F posed dorsal urethral plate. A few stitches fixed the ven- Foley catheter was left in place for 3 weeks. Patients tral spongiosum to the graft. Finally the adventitia of were usually discharged from the hospital 3 days after the spongiosum was closed over the graft [4,11]. surgery and underwent VCUG 3 weeks later. Figure 2 Kaplan–Meier curves showing the correlation between success rate and (a) graft type, (b) stricture length, and (c) history of urethral dilatation before surgery. 122 Palminteri et al. Follow-up Table 2 The 5-year actuarial success rate in the study groups. The follow-up assessment included recording any com- Variable n cases Success P plaints after urethroplasty (urinary, genital and ejacula- rate (%) tory) by a simple clinical interview, uroflowmetry and All 216 91.4 urine culture every 4 months in the first year and annu- Graft type ally thereafter. Whenever obstructive symptoms devel- Dorsal 32 87.8 oped or the peak urinary flow rate deteriorated to Ventral 121 95.5 <14 mL/s, urethrography and urethroscopy were per- Dorsal + ventral 63 86.3 0.162 formed. Successful reconstruction was defined as normal Age (years) voiding with no need for any postoperative procedure, <50 167 90.4 including dilatation [4,6,10]. All patients were followed P50 49 94.8 0.336 up for at least 12 months, the mean (SD, range) being Length of stricture (cm) 37 (19.8, 12–113) months. 64 180 93.3 >4 36 82.3 0.026 Statistical analysis Previous urethrotomy None 75 92.1 1 59 89.4 Data are presented as the mean (SD) or median, and >1 82 92.1 0.915 groups were compared using the chi-square and Stu- dent’s t-tests. The 5-year actuarial success rates were Previous dilatation No 154 93.4 estimated by Kaplan–Meier curves and differences be- Yes 62 84.9 0.058 tween groups were calculated using the log-rank test. Previous urethroplasties Risk factors were assessed by calculating the odds ratio No 200 91.2 using bivariable analyses. To study the independent ef- Yes 16 93.8 0.958 fect of prognostic factors on estimates of success rate, P < 0.05 was considered significant. only at least borderline significant variables were entered into a multivariable analysis with a Cox proportional- hazards model. Statistical significance was considered the only independent factor that retained statistical sig- to be indicated at P < 0.05. The study was approved nificance on the multivariable analysis. The odds of fail- by the local ethics committee. ure among cases with a stricture length of >4 cm were three times more than those with a length of 64 cm, Results with a 95% CI of 1.09–8.22. Among successful cases, there was a marked improvement in peak urinary flow rate from a mean In 11 (5%) cases, at VCUG after catheter removal, there (range) preoperative value of 8.64 (2–15) mL/s to a was a fistula that resolved spontaneously with insertion mean postoperative value of 28.5 (14–49.6) mL/s at of a 12-F catheter for two additional weeks; two cases the last follow-up (P < 0.001). were in the DGU group, five in the VGU group, and Sexual complaints were not reported by any of the four in the DVGU group. Two patients had a perineal patients. Of 16 failures, three were in the DGU group, haematoma that was drained on the third day after five in the VGU group and eight in the DVGU group. surgery. Ten patients developed a short re-stricture at the distal The overall 5-year actuarial success rate of the whole or proximal site of the reconstruction; they were treated series was 91.4%. The 5-year actuarial success rates were with one internal urethrotomy in nine cases and with 87.8%, 95.5% and 86.3% for the DGU, VGU and two urethrotomies in one case. In six patients the re- DVGU groups, respectively. There were no statistically stricture involved the entire grafted area; they were trea- significant differences among the groups (Fig. 2a, ted with perineostomy and are currently waiting for a P = 0.162). The stricture length had a significant effect staged solution. on the 5-year actuarial success rate, with strictures of 64 cm having a better prognosis (Fig. 2b P = 0.026). Patients with no history of urethral dilatation before Discussion treatment had a better 5-year actuarial success rate, that was almost significant (Fig. 2c, P = 0.058). However, In our experience, using the ventral approach, the ven- patient age, previous urethrotomy and previous urethro- tral, dorsal and dorsal–ventral grafting techniques plasties had no statistically significant (P > 0.05) effect showed good 5-year actuarial success rates (95.5%, on the 5-year actuarial success rate (Table 2). 87.8% and 86.3%, respectively). Our VGUs had a suc- Significant and borderline significant variables on cess rate (95.5%) similar to the 90–91.4% reported by bivariable analyses were entered into a multivariable others [11,12]. Our DGUs by a ventral urethral ap- Cox proportional-hazard model. Stricture length was proach had a success rate (87.8%) similar to that of Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts 123 dorsal graft techniques by a dorsal urethrotomy ap- graft, double grafting might decrease the chance of fistu- proach (90–98%), as reported by others using a similar lae and diverticula. The dorsal augmentation is rather follow-up interval [2]. small, due to the difficulty of mobilisation of the ure- However, even though many surgeons prefer to use thral plate that the ventral approach entails. Thus, the the popular dorsal approach, recent overviews have con- additional second graft could correct the initial use of firmed that ventral or dorsal graft procedures have a a single dorsal graft that was later judged to be insuffi- similar success rate [13,14]. Thus, larger prospective ran- cient for an adequate augmentation. Avoiding a com- domised studies with a longer follow-up will be needed plete section of the spongiosum, the DVGU preserves to analyse differences in outcome between the the urethral plate and urethral vascularity [10,18]. The approaches. aim was to maintain the urethral axial integrity and Our success rate (90%) for graft urethroplasties for the original urethral length, reducing the hypothetical strictures of 1.5–2 cm was comparable with success rates sexual complications related to the AU [16,19–22]. (87–96%) reported in different series of anastomotic Abouassaly and Angermeier [18] advised against the urethroplasty (AU) [12,15]. Al-Qudah and Santucci use of the AU in cases with distal urethral disease, in [16] suggested that AU is controversial for treating ure- which the urethral transection would further compro- thral strictures of 0.5–3 cm. They presented a series of mise the blood supply. Furthermore, they stated that, short strictures treated with AU or BM graft and com- following the urethral transection, the stricture could pared the results; the recurrence rate was 7% in the be longer than that seen on urethrography, and it could AU group and 0% in the BM group; sexual complica- cause difficulty in making the AU, with an increased risk tions occurred in 18% of the patients after AU. In the of complications. Conversely, the ventral urethral open- present series, none of the patients reported sexual dys- ing allows the surgeon to choose an adequate solution function. Nevertheless, similar to other investigators after evaluating the stricture and its length [18]. [17], we did not use a validated questionnaire for a rig- In the present study we reviewed our results accord- orous assessment of sexual function. Thus, a larger ser- ing to the factors that can potentially influence the suc- ies with a longer follow-up and adapted questionnaires cess rate of the urethroplasties. Stricture aetiology, will be needed to clarify whether, for short non-obliter- patient age, and previous urethrotomy or urethroplasty ating bulbar strictures, graft techniques could represent had no statistically significant effect on the results, an alternative to the traditional AU, which is supported whilst the success rate decreased with stricture lengths by the current evidence as the method of choice. of >4 cm. Traditionally, the older ventral urethrotomy has been The main weakness of the present study is that it was considered an easy access to the urethral lumen, and which retrospective and not prospective. The population could gives a good visualisation of the strictured tract [3,4,11].As not be considered homogeneous for the number of pa- there is no mobilisation-rotation of the urethra, it is very tients, stricture aetiology and characteristics, patient’s simple to perform, particularly for reconstructive urolo- characteristics, and surgeon’s preference. This could gists under training with insufficient experience. bias the statistical analysis. Nevertheless, our study The better visualisation of the urethral plate by the showed clearly that a BM graft through a ventral ure- ventral opening can allow any of the three solutions, throtomy access is a versatile technique that could be i.e. dorsal, ventral, or dorsal plus ventral graft augmen- used for dorsal, ventral or combined dorsal and ventral tation. The choice of graft placement is conditioned by grafting, with comparable success rates. the site of the stricture within the bulbar urethra and In conclusion, in graft bulbar urethroplasties, the by the characteristics of the urethral plate. Generally, ventral urethrotomy approach appears to be simple we used the dorsal graft in strictures in the distal or mid- and versatile because it allows a better visualisation of dle bulbar urethra, where the corpora represent a valid the urethral plate, and it permits any of the three differ- support for the graft. In the proximal bulbar urethra ent solutions, i.e. dorsal, ventral, or dorsal plus ventral the split corpora precludes this support; furthermore, graft augmentation. The dorsal or ventral grafting is the difficulty of working dorsally in the deep bulb, and used according to the stricture characteristics and site the substantial ventral spongiosum encourage ventral within the bulbar urethra. The double dorsal plus ven- grafting [6]. In tight strictures with a very narrow ure- tral graft is useful in tight strictures in which a single thral plate, in which a single patch seemed to be insuffi- graft augmentation is insufficient. Using the ventral ap- cient to reconstruct an adequate lumen, we preferred the proach, all three grafting techniques had a comparable dorsal plus ventral double grafting. Also, Elliot et al. success rate, which decreased with the increase of stric- [11] stated that in the presence of a very narrow urethral ture length. plate, the standard ventral augmentation could be inad- equate, suggesting the use of a 2.5-mm wider graft. Conflict of interest In 2008, we introduced the use of DVGU, postulating some advantages [10]. Avoiding a wide single ventral No conflict of interest to declare. 124 Palminteri et al. [12] Barbagli G, Guazzoni G, Lazzeri M. One-stage bulbar urethro- References plasty. Retrospective analysis of the results in 375 patients. Eur Urol 2008;53:828–33. [1] Andrich DE, Mundy AR. What is the best technique for [13] Wang K, Miao X, Wang L. Dorsal versus ventral onlay urethroplasty? Eur Urol 2008;54:1031–41. urethroplasty for anterior urethral stricture: a meta-analysis. Urol [2] Patterson JM, Chapple CR. Surgical techniques in substitution Int 2009;83:342–8. urethroplasty using buccal mucosa for the treatment of anterior [14] Barbagli G, Lizzeri M. Surgical treatment of anterior urethral urethral strictures. Eur Urol 2008;53:1162–71. stricture diseases: brief overview. Int Braz J Urol 2007;33:461–9. [3] Presman D, Greenfield DL. Reconstruction of the perineal [15] Santucci RA, Mario LA, McAninch JW. Anastomotic urethro- urethra with a free full-thickness skin graft of the prepuce. J plasty for bulbar urethral stricture. Analysis of 168 patients. J Urol 1953;69:677–80. Urol 2002;167:1715–9. [4] Morey AF, McAninch JW. When and how to use buccal mucosal [16] Al-Qudah HS, Santucci RA. Buccal mucosal onlay urethroplasty grafts in adult bulbar urethroplasty. Urology 1996;48:194–8. versus anastomotic urethroplasty (AU) for short urethral stric- [5] Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft tures: which is better? J Urol (Suppl) 2006;175:103 [(Abstract) urethroplasty. J Urol 1996;155:123–6. 313]. [6] Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, [17] O’Riordan A, Narahari R, Kumar V, Pickard R. Outcome of Lazzeri M. Bulbar urethroplasty using buccal mucosa grafts dorsal buccal graft urethroplasty for recurrent bulbar urethral placet on the ventral, dorsal or lateral surface of the urethra: are strictures. BJU Int 2008;102:1148–51. results affected by the surgical technique? J Urol 2005;174:955–8. [18] Abouassaly R, Angermeier KW. Augmented anastomotic ure- [7] Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for throplasty. J Urol 2007;177:2211–6. repair of bulbar urethral stricture. J Urol 1999;161:815–8. [19] Guralnick ML, Webster GD. The augmented anastomotic [8] Asopa H, Garg M, Singhal GG, Singh L, Asopa J, Nischal A. urethroplasty. Indications and outcome in 29 patients. J Urol Dorsal free graft urethroplasty for urethral stricture by ventral 2001;165:1496–501. sagittal urethrotomy approach. Urology 2001;58:657–9. [20] Morey AF, Kizer WS. Proximal bulbar urethroplasty via [9] Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided extended anastomotic approach – what are the limits? J Urol anterior urethroplasty: a new dorsal onlay graft technique. BJU 2006;175:2145–9. Int 2009;104:1150–5. [21] Barbagli G, De Angelis M, Romano G, Lazzeri M. Long-term [10] Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, followup of bulbar end-to-end anastomosis: a retrospective Poluzzi M, et al.. Combined dorsal plus ventral double buccal analysis of 153 patients in a single center experience. J Urol mucosa graft in bulbar urethral reconstruction. Eur Urol 2007;178:2470–3. 2008;53:81–90. [22] Mundy AR. Results and complications of urethroplasty and its [11] Elliot SP, Metro MJ, McAninch JW. Long-term followup of the future. Br J Urol 1993;71:322–5. ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction. J Urol 2003;169:1754–7. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Arab Journal of Urology Taylor & Francis

Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts

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Abstract

Arab Journal of Urology (2012) 10, 118–124 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ONCOLOGY/RECONSTRUCTION ORIGINAL ARTICLE Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts a, a b c Enzo Palminteri , Elisa Berdondini , Ferdinando Fusco , Cosimo De Nunzio , d e Kostas Giannitsas , Ahmed A. Shokeir Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy Department of Urology, University Federico II, Naples, Italy Department of Urology, Sant’Andrea Hospital, ‘La Sapienza’ University, Rome, Italy Urology Department, Patras University Hospital, Patras, Greece Urology & Nephrology Center, Mansoura, Egypt Received 12 January 2012, Received in revised form 24 February 2012, Accepted 25 February 2012 Available online 20 April 2012 KEYWORDS Abstract Objectives: To investigate the versatility of the ventral urethrotomy approach in bulbar reconstruction with buccal mucosa (BM) grafts placed on the Urethra; dorsal, ventral or dorsal plus ventral urethral surface. Stricture; Patients and methods: Between 1999 and 2008, 216 patients with bulbar strictures Urethroplasty; underwent BM graft urethroplasty using the ventral-sagittal urethrotomy approach. Buccal mucosa; Of these patients, 32 (14.8%; mean stricture 3.2 cm, range 1.5–5) had a dorsal graft Graft urethroplasty (DGU), 121 (56%; mean stricture 3.7, range 1.5–8) a ventral graft ure- throplasty (VGU), and 63 (29.2%; mean stricture 3.4, range 1.5–10) a dorsal plus ABBREVIATIONS ventral graft urethroplasty (DVGU). The strictured urethra was opened by a ven- AU, anastomotic ure- tral-sagittal urethrotomy and BM graft was inserted dorsally or ventrally or dorsal throplasty; BM, buccal plus ventral to augment the urethral plate. mucosa; Results: The median follow-up was 37 months. The overall 5-year actuarial suc- (D)(V)(DV)GU, (dor- cess rate was 91.4%. The 5-year actuarial success rates were 87.8%, 95.5% and sal) (ventral) (dorsal Corresponding author. Address: Centre for Urethral and Genitalia Reconstructive Surgery, Via Fra’ Guittone 2, 52100 Arezzo, Italy. Tel.: +39 3357012783; fax: +39 057527056. E-mail address: enzo.palminteri@inwind.it (E. Palminteri). 2090-598X ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Production and hosting by Elsevier Peer review under responsibility of Arab Association of Urology. http://dx.doi.org/10.1016/j.aju.2012.02.009 Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts 119 plus ventral) graft ure- 86.3% for the DGU, VGU and DVGU, respectively. There were no statistically sig- throplasty; VCUG, nificant differences among the three groups. Success rates decreased significantly voiding cysto- only with a stricture length of >4 cm. urethrography Conclusions: In BM graft bulbar urethroplasties the ventral urethrotomy access is simple and versatile, allowing an intraoperative choice of dorsal, ventral or com- bined dorsal and ventral grafting, with comparable success rates. ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction when the dissection from the corpora needs to be very proximal [6,7]. The dorsal urethral mobilisation was shown to be difficult in scarred urethras with marked Buccal mucosa (BM) is considered the reference stan- periurethral fibrosis after previous treatments [8]; even dard urethral substitute in graft bulbar urethroplasties, an extensive dorsal approach could cause urethral and its dorsal or ventral placement using the dorsal or ischaemia. Therefore, in 2001, Asopa et al. [8] described ventral urethrotomy approaches has become a conten- a different dorsal graft using a ventral urethrotomy ap- tious issue, with no resolution to date [1,2]. proach, stating that the procedure is easier because the In 1953, Presman and Greenfield [3] introduced ven- urethra is not mobilised. Recently, Kulkarni et al. [9] tral grafting by a ventral urethrotomy, which gives easy elaborated a modified dorso-lateral approach which pre- access to the urethra and good visualisation of the stric- serves one lateral vascular supply to the urethra. In ture. In 1996, this technique was revived by Morey and 2008, we described, for the first time, the combined dor- McAninch [4]. sal plus ventral double graft for repairing very tight bul- In 1996, Barbagli et al. [5] introduced the novelty of bar strictures [10]. dorsal grafting by a dorsal urethrotomy. Nevertheless, To investigate the feasibility, efficacy and versatility the same authors recognised that the dorsal approach of the ventral approach, in the present study we retro- is simpler in the distal bulbar urethra, whereas the ven- spectively evaluated and statistically analysed outcomes tral approach with ventral grafting is more effective in in 216 patients who underwent graft bulbar urethro- the proximal bulbar urethra, where the spongiosum tis- plasty using a ventral urethrotomy access, and with sue is thick [6]. Also they advised that dorsal access the BM placed on the dorsal, ventral or dorsal plus might damage erectile function and the bulbar arteries Table 1 Patients and stricture characteristics in the three study groups. Variable DGU VGU DVGU No. patients 32 121 63 Age (years), Mean ± (SD) 39.2 (16.2) 39.2 (13.3) 39.0 (14.3) Cause of stricture, n Unknown 19 83 41 Catheter 6 27 17 Instrumentation 4 8 2 Trauma 3 3 2 Infection 0 0 1 Previous treatment, n (%) 23 (71.9) 84 (69.4) 43 (68.2) Dilatations 20 26 16 Urethrotomy 19 80 42 Urethroplasty 4 10 2 None 9 37 20 Mean (SD) Stricture length (cm) 3.2 (1.1) 3.7 (1.2) 3.4 (1.4) Range 1.5–5 1.5–8 1.5–10 Stricture length (cm), n 1.5–2 10 11 9 >2–4 17 85 48 >4–6 5 21 4 >6 0 4 2 Median (range) follow-up (months) 43 (12–107) 27 (12–113) 49 (12–85) One patient may receive more than one treatment. 120 Palminteri et al. ventral surface of the urethra. We also analysed the risk thral plate, it is easy to expose the corpora. A ventral factors that could affect the success rate over a median graft was preferred in strictures located in the proximal follow-up of 37 months, using both bivariable and mul- bulbar urethra where it is difficult to work dorsally and tivariable analyses. the split of the corpora causes a lack of adequate sup- port for the graft; furthermore, the abundant ventral Patients and methods spongiosum provides adequate vascularisation and sup- port for the graft [4]. Finally, the dorsal plus ventral Patients double graft was used in tight strictures with a narrow residual urethral plate (<5 mm) in which a single patch seemed to be insufficient to make a sufficiently wide We reviewed the charts of patients with bulbar urethral lumen. strictures who underwent BM graft bulbar urethroplasty Baseline patient and stricture characteristics are by a ventral-sagittal urethrotomy approach. The study shown in Table 1. The preoperative evaluation included included 216 consecutive patients who were treated be- a clinical history, physical examination, oral cavity tween 1999 and 2008 and had completed a minimum fol- examination, urine culture, uroflowmetry, retrograde low-up of 12 months. None of the patients was lost to and voiding cysto-urethrography (VCUG) and ure- follow-up. Patients with lichen sclerosis and failed hypo- throscopy. All patients were informed of the rare post- spadias repair were excluded. The study population was operative complications at the oral donor site. divided into three groups according to the location of the BM graft: dorsal, ventral or combined dorsal and Surgical technique ventral. The techniques were selected according to the site and All surgical procedures were carried out by the same length of the stricture within the bulbar urethra, and urologist (E.P.). Through an inverted-Y incision the according to the quality of the urethral plate. Generally, bulbocavernous muscles were divided, exposing the bul- we used the dorsal graft in strictures located in the distal bar urethra. The strictured tract was opened by the or middle bulbar urethra where, after incising the ure- Figure 1 Diagram illustrating DGU, VGU, and DVGU, using a ventral-sagittal urethrotomy approach. Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts 121 ventral-sagittal urethrotomy approach, exposing the Dorsal plus ventral graft urethroplasty (DVGU) urethral plate, and then the BM patch graft was inserted The exposed dorsal urethral plate was incised in the dorsally, ventrally or dorsally ventrally to augment the midline to create an elliptical area where the first dor- urethra (Fig. 1). Of 216 urethroplasties, the graft was sal-inlay graft was placed to augment the urethra dor- placed on the dorsal urethral surface using the technique sally. Subsequently, the second ventral-onlay graft was of Asopa et al. in 32 (14.8%) cases, on the ventral sur- sutured to the lateral urethral margins to complete ven- face in 121 (56%) and on the dorsal plus ventral surface trally the augmented urethroplasty by preserving the by our previously described technique [10] in 63 urethral plate. Finally, the spongiosum was closed over (29.2%). the graft [10]. Dorsal graft urethroplasty (DGU) Harvesting of BM The exposed dorsal urethral plate was incised in the The BM was harvested from the cheek. Of 153 DGUs midline down to the tunica albuginea. The margins of and VGUs, the BM was harvested from the right cheek the incised dorsal urethra were dissected from the tunica in 152 patients and from both cheeks in one. Of 63 without lifting the two halves of the bisected urethra. An DVGUs, 58 patients had a wide single graft harvested elliptical raw area was created over the tunica where the from one cheek and subsequently tailored into two graft was placed and sutured. A catheter was inserted smaller grafts, according to the length of the dorsal and the lateral margins of the augmented urethral plate and ventral urethral openings, while in four patients were sutured together with a running suture. Finally the the two grafts were harvested bilaterally from both adventitia of the spongiosum was closed [8]. cheeks. The mean (SD, range) length of the harvested BM graft was 6 (0.36, 5–8) cm and the width was 1.7 Ventral graft urethroplasty (VGU) (0.38, 1–2.5) cm. The graft was sutured to the mucosal margins of the ex- A suction drain was left in place for 2 days. An 18-F posed dorsal urethral plate. A few stitches fixed the ven- Foley catheter was left in place for 3 weeks. Patients tral spongiosum to the graft. Finally the adventitia of were usually discharged from the hospital 3 days after the spongiosum was closed over the graft [4,11]. surgery and underwent VCUG 3 weeks later. Figure 2 Kaplan–Meier curves showing the correlation between success rate and (a) graft type, (b) stricture length, and (c) history of urethral dilatation before surgery. 122 Palminteri et al. Follow-up Table 2 The 5-year actuarial success rate in the study groups. The follow-up assessment included recording any com- Variable n cases Success P plaints after urethroplasty (urinary, genital and ejacula- rate (%) tory) by a simple clinical interview, uroflowmetry and All 216 91.4 urine culture every 4 months in the first year and annu- Graft type ally thereafter. Whenever obstructive symptoms devel- Dorsal 32 87.8 oped or the peak urinary flow rate deteriorated to Ventral 121 95.5 <14 mL/s, urethrography and urethroscopy were per- Dorsal + ventral 63 86.3 0.162 formed. Successful reconstruction was defined as normal Age (years) voiding with no need for any postoperative procedure, <50 167 90.4 including dilatation [4,6,10]. All patients were followed P50 49 94.8 0.336 up for at least 12 months, the mean (SD, range) being Length of stricture (cm) 37 (19.8, 12–113) months. 64 180 93.3 >4 36 82.3 0.026 Statistical analysis Previous urethrotomy None 75 92.1 1 59 89.4 Data are presented as the mean (SD) or median, and >1 82 92.1 0.915 groups were compared using the chi-square and Stu- dent’s t-tests. The 5-year actuarial success rates were Previous dilatation No 154 93.4 estimated by Kaplan–Meier curves and differences be- Yes 62 84.9 0.058 tween groups were calculated using the log-rank test. Previous urethroplasties Risk factors were assessed by calculating the odds ratio No 200 91.2 using bivariable analyses. To study the independent ef- Yes 16 93.8 0.958 fect of prognostic factors on estimates of success rate, P < 0.05 was considered significant. only at least borderline significant variables were entered into a multivariable analysis with a Cox proportional- hazards model. Statistical significance was considered the only independent factor that retained statistical sig- to be indicated at P < 0.05. The study was approved nificance on the multivariable analysis. The odds of fail- by the local ethics committee. ure among cases with a stricture length of >4 cm were three times more than those with a length of 64 cm, Results with a 95% CI of 1.09–8.22. Among successful cases, there was a marked improvement in peak urinary flow rate from a mean In 11 (5%) cases, at VCUG after catheter removal, there (range) preoperative value of 8.64 (2–15) mL/s to a was a fistula that resolved spontaneously with insertion mean postoperative value of 28.5 (14–49.6) mL/s at of a 12-F catheter for two additional weeks; two cases the last follow-up (P < 0.001). were in the DGU group, five in the VGU group, and Sexual complaints were not reported by any of the four in the DVGU group. Two patients had a perineal patients. Of 16 failures, three were in the DGU group, haematoma that was drained on the third day after five in the VGU group and eight in the DVGU group. surgery. Ten patients developed a short re-stricture at the distal The overall 5-year actuarial success rate of the whole or proximal site of the reconstruction; they were treated series was 91.4%. The 5-year actuarial success rates were with one internal urethrotomy in nine cases and with 87.8%, 95.5% and 86.3% for the DGU, VGU and two urethrotomies in one case. In six patients the re- DVGU groups, respectively. There were no statistically stricture involved the entire grafted area; they were trea- significant differences among the groups (Fig. 2a, ted with perineostomy and are currently waiting for a P = 0.162). The stricture length had a significant effect staged solution. on the 5-year actuarial success rate, with strictures of 64 cm having a better prognosis (Fig. 2b P = 0.026). Patients with no history of urethral dilatation before Discussion treatment had a better 5-year actuarial success rate, that was almost significant (Fig. 2c, P = 0.058). However, In our experience, using the ventral approach, the ven- patient age, previous urethrotomy and previous urethro- tral, dorsal and dorsal–ventral grafting techniques plasties had no statistically significant (P > 0.05) effect showed good 5-year actuarial success rates (95.5%, on the 5-year actuarial success rate (Table 2). 87.8% and 86.3%, respectively). Our VGUs had a suc- Significant and borderline significant variables on cess rate (95.5%) similar to the 90–91.4% reported by bivariable analyses were entered into a multivariable others [11,12]. Our DGUs by a ventral urethral ap- Cox proportional-hazard model. Stricture length was proach had a success rate (87.8%) similar to that of Versatility of the ventral approach in bulbar urethroplasty using dorsal, ventral or dorsal plus ventral oral grafts 123 dorsal graft techniques by a dorsal urethrotomy ap- graft, double grafting might decrease the chance of fistu- proach (90–98%), as reported by others using a similar lae and diverticula. The dorsal augmentation is rather follow-up interval [2]. small, due to the difficulty of mobilisation of the ure- However, even though many surgeons prefer to use thral plate that the ventral approach entails. Thus, the the popular dorsal approach, recent overviews have con- additional second graft could correct the initial use of firmed that ventral or dorsal graft procedures have a a single dorsal graft that was later judged to be insuffi- similar success rate [13,14]. Thus, larger prospective ran- cient for an adequate augmentation. Avoiding a com- domised studies with a longer follow-up will be needed plete section of the spongiosum, the DVGU preserves to analyse differences in outcome between the the urethral plate and urethral vascularity [10,18]. The approaches. aim was to maintain the urethral axial integrity and Our success rate (90%) for graft urethroplasties for the original urethral length, reducing the hypothetical strictures of 1.5–2 cm was comparable with success rates sexual complications related to the AU [16,19–22]. (87–96%) reported in different series of anastomotic Abouassaly and Angermeier [18] advised against the urethroplasty (AU) [12,15]. Al-Qudah and Santucci use of the AU in cases with distal urethral disease, in [16] suggested that AU is controversial for treating ure- which the urethral transection would further compro- thral strictures of 0.5–3 cm. They presented a series of mise the blood supply. Furthermore, they stated that, short strictures treated with AU or BM graft and com- following the urethral transection, the stricture could pared the results; the recurrence rate was 7% in the be longer than that seen on urethrography, and it could AU group and 0% in the BM group; sexual complica- cause difficulty in making the AU, with an increased risk tions occurred in 18% of the patients after AU. In the of complications. Conversely, the ventral urethral open- present series, none of the patients reported sexual dys- ing allows the surgeon to choose an adequate solution function. Nevertheless, similar to other investigators after evaluating the stricture and its length [18]. [17], we did not use a validated questionnaire for a rig- In the present study we reviewed our results accord- orous assessment of sexual function. Thus, a larger ser- ing to the factors that can potentially influence the suc- ies with a longer follow-up and adapted questionnaires cess rate of the urethroplasties. Stricture aetiology, will be needed to clarify whether, for short non-obliter- patient age, and previous urethrotomy or urethroplasty ating bulbar strictures, graft techniques could represent had no statistically significant effect on the results, an alternative to the traditional AU, which is supported whilst the success rate decreased with stricture lengths by the current evidence as the method of choice. of >4 cm. Traditionally, the older ventral urethrotomy has been The main weakness of the present study is that it was considered an easy access to the urethral lumen, and which retrospective and not prospective. The population could gives a good visualisation of the strictured tract [3,4,11].As not be considered homogeneous for the number of pa- there is no mobilisation-rotation of the urethra, it is very tients, stricture aetiology and characteristics, patient’s simple to perform, particularly for reconstructive urolo- characteristics, and surgeon’s preference. This could gists under training with insufficient experience. bias the statistical analysis. Nevertheless, our study The better visualisation of the urethral plate by the showed clearly that a BM graft through a ventral ure- ventral opening can allow any of the three solutions, throtomy access is a versatile technique that could be i.e. dorsal, ventral, or dorsal plus ventral graft augmen- used for dorsal, ventral or combined dorsal and ventral tation. The choice of graft placement is conditioned by grafting, with comparable success rates. the site of the stricture within the bulbar urethra and In conclusion, in graft bulbar urethroplasties, the by the characteristics of the urethral plate. Generally, ventral urethrotomy approach appears to be simple we used the dorsal graft in strictures in the distal or mid- and versatile because it allows a better visualisation of dle bulbar urethra, where the corpora represent a valid the urethral plate, and it permits any of the three differ- support for the graft. In the proximal bulbar urethra ent solutions, i.e. dorsal, ventral, or dorsal plus ventral the split corpora precludes this support; furthermore, graft augmentation. The dorsal or ventral grafting is the difficulty of working dorsally in the deep bulb, and used according to the stricture characteristics and site the substantial ventral spongiosum encourage ventral within the bulbar urethra. The double dorsal plus ven- grafting [6]. In tight strictures with a very narrow ure- tral graft is useful in tight strictures in which a single thral plate, in which a single patch seemed to be insuffi- graft augmentation is insufficient. Using the ventral ap- cient to reconstruct an adequate lumen, we preferred the proach, all three grafting techniques had a comparable dorsal plus ventral double grafting. Also, Elliot et al. success rate, which decreased with the increase of stric- [11] stated that in the presence of a very narrow urethral ture length. plate, the standard ventral augmentation could be inad- equate, suggesting the use of a 2.5-mm wider graft. Conflict of interest In 2008, we introduced the use of DVGU, postulating some advantages [10]. Avoiding a wide single ventral No conflict of interest to declare. 124 Palminteri et al. [12] Barbagli G, Guazzoni G, Lazzeri M. One-stage bulbar urethro- References plasty. Retrospective analysis of the results in 375 patients. Eur Urol 2008;53:828–33. 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Journal

Arab Journal of UrologyTaylor & Francis

Published: Jun 1, 2012

Keywords: Urethra; Stricture; Urethroplasty; Buccal mucosa; Graft; AU; anastomotic urethroplasty; BM; buccal mucosa; (D)(V)(DV)GU; (dorsal) (ventral) (dorsal plus ventral) graft urethroplasty; VCUG; voiding cysto-urethrography

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