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32.5 Urethroplasty withAutologous Graft
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273
a
b
e
Fig. 32.8 Dorsolataral onlay (Kulkarni technique). (a) The urethra is mobilized from the albu-
ginea only along the left side. (b) The dorsolateral side of the urethra is incised longitudinally. (c)
The oral mucosa graft is sutured to the underlying albuginea, and the right margin of the oral graft
is sutured to the left margin of the urethral plate (d) and on the other side. (e) Cross-sectional view
of the grafted urethral lumen. BF Buck’s fascia, CC corpora cavernosum, CS corpus spongiosum,
OM oral mucosa, TA tunica albuginea, UMP urethral mucosal plate. (From Horiguchi A [22], with
permission from John Wiley and Sons)
32.5.2.3 Kulkarni One-Side Dorsolateral Approach (Fig.32.8)
In 2009, Kulkarni etal. proposed a modied technique of the Barbagli dorsal onlay
buccal mucosa urethroplasty: the so-called one-side dorsolateral approach avoid-
ing the full circumferential mobilization of the urethra, hence minimizing the
risk of vascular compromise [23].
The steps of this technique are [22–25]:
– midline perineal incision.
– dissection of the bulbar urethra only on one side (left side for right-handed
surgeons).
– leave the bulbospongiosus muscle and the central tendon of the perineum intact.
– Invagination of the penis into the incision and dissection of the penile ure-
thra on one side only.
– rotation and dorsal incision of the urethra to expose the whole stricture.
– Deep external meatotomy at 12 o’clock position
– Fixation of the buccal mucosa graft to the dorsal aspect of the meatus using three
single 5/0 resorbable sutures.
– Pushing the graft inside and xation to the corpora cavernosa with 5/0 resorbable
sutures on 2, 10, 12 o’clock positions.
– Further xation of the graft with multiple quilting sutures.
– Insertion of a 14–16 Fr silicone Foley catheter (will be kept for one month).
– Completion of the anastomosis on the left side.
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32 Treatment ofUrethral Injury. II: TheAnterior Urethra
This technique yielded a 92% success rate and was validated by subsequent studies showing comparable success rates using either a buccal graft or the penile skin
as well as reproducibility even in panurethral stricture where the penile invagination
is particularly useful to expose the whole length of the urethra and the use of two or
three buccal grafts is necessary [24–26] (Figs.32.9, 32.10, and 32.11).
Note: In view of the abundant and eventually confusing technical information
contained in the paragraphs above, the following sentence might help as a useful
mnemonic to make the correct associations between the eponyms and their corresponding techniques and to memorize the salient aspects of the dorsal graft
urethroplasty:
“ASIN deed the BARON by refusing to dance around the palm tree, then
KUONG proposed to limit the dance to one side of the tree”.
In this sentence:
– ASIN stands for Asopa+Inlay, BARON stands for Barbagli+Onlay, KUONG
stands for Kulkarni+Unilateral+Onlay+graft.
– The refusal to dance around the palm tree refers to the avoidance by Asopa’s
technique to mobilize the urethra all around as preconized by Barbagli etal.
Fig. 32.9 The penis is
invaginated into the
incision and penile urethra
is dissected only on the left
side leaving the urethra
attached to the corpora
cavernosa on the right and
preserving its
neurovascular supply.
(From Zumrutbas AE [25],
with permission from
Springer Nature)
32.5 Urethroplasty withAutologous Graft
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Fig. 32.10 The buccal
mucosal graft is sutured to
the dorsal aspect of the
meatus using three single
5/0 polyglactin sutures and
the graft is pushed inside
through the meatus. (From
Zumrutbas AE [25], with
permission from Springer
Nature)
Fig. 32.11 A 14F silicone
Foley catheter is inserted
and anastomosis is
completed on the left side.
(From Zumrutbas AE [25],
with permission from
Springer)
275
– The one-side dance is the unilateral technique of Kulkarni’s approach avoiding
the complete mobilization of the urethra.
Note that Asin is a girl’s rst name in India. Readers from Arab countries may
use Inas instead.
Further modication of Barbagli dorsal onlay technique includes the use of
brine glue to x the graft on the corpora cavernosa [27, 28] (Figs.32.12, 32.13,
and 32.14).
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Fig. 32.12 After one-side
mobilization of the urethra,
a brin glue (2mL) is
injected over the corpora
cavernosa. (From Barbagli
G etal. [28], with
permission from John
Wiley and Sons)
32 Treatment ofUrethral Injury. II: TheAnterior Urethra
When the strictured area is too narrow, one graft might not be enough to ensure
adequate lumen without transecting the urethra. Herein, Palminteri etal. proposed
the use of two grafts, the so-called combined dorsal plus ventral double buccal
mucosa graft [29] (Figs.32.15, 32.16, and 32.17).
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Fig. 32.13 The oral
mucosal graft, trimmed to
an appropriate size
according to the length and
width of the urethrotomy,
is spread, optionally xed
over the brin-glue bed,
and the apices of the graft
are sutured to the proximal
and distal apices of the
urethrotomy. (From
Barbagli G etal. [28], with
permission from John
Wiley and Sons)
277
Urethroplasty is rarely performed in females where the possibility for vaginal
mucosa graft exists in addition to the buccal mucosa [30], and the vaginal ap can
be harvested from the anterior (Blandy ap) or the lateral wall (Orandi ap) [31]*.
*The Orandi ap was rst described by Ahmad Orandi in 1968in males with
anterior urethral strictures and consisted of the use of an inverted penile skin ap
[32]. It is rarely used nowadays.
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Fig. 32.14 The margin of
the oral graft is sutured to
the margin of the urethral
mucosal plate on the right
side, and a Foley 16-F
grooved silicone catheter
will be inserted before
completing the urethral
retubularization on the left
side. (From Barbagli G
etal. [28], with permission
from John Wiley and Sons)
32 Treatment ofUrethral Injury. II: TheAnterior Urethra
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279
a
Fig. 32.15 Dorsal inlay patch augmentation. (a and b) The rst buccal mucosa graft is sutured
and quilted into the recipient elliptical area. (From Palminteri E etal. [29], with permission from
Elsevier)
b
Fig. 32.16 Ventral onlay patch augmentation. (a) The second buccal mucosa graft is sutured later-
ally to the mucosal margin of the urethral plate. (b) The graft is rotated and sutured to the other
mucosal margin. (From Palminteri E etal. [29], with permission from Elsevier)
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32 Treatment ofUrethral Injury. II: TheAnterior Urethra
a
b
c
Fig. 32.17 (a and b) The inverted ventral graft is quilted by few stitches xing the graft to the
spongiosum. (c) Spongiosum closure over the graft. (From Palminteri E etal. [29], with permission from Elsevier)
32.6 Alternative Treatment
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281
32.6 Alternative Treatment
32.6.1 Endoscopic Realignment
Immediate endoscopic-guided urethral splinting (railroading procedure) has been
advocated for stable patients with complete anterior urethral disruption. The procedure consists of a retrograde urethroscopy with or without antegrade cystoscopy
under uoroscopic guidance through suprapubic access and proceeds through the
negotiation of a guidewire across the disrupted segment followed by a Foley catheter insertion. This technique proved to be safe and feasible in almost all well-selected
patients and showed no recurrence in more than half of the cases [33].
32.6.1.1 Endoprosthesis
The Urolume endoprosthesis has been proposed as a minimally invasive treatment
for recurrent bulbar urethral stricture, BPH, and detrusor-external sphincter dyssynergia in the late 1980s [34, 35]. However, subsequent researchers did not show
much enthusiasm due to frequent complications, namely migration, recurrent stenosis, urethral pain, recurrent urinary tract infections, and the use of the Urolume
endoprosthesis fell into desuetude [36, 37].
Recently, the randomized Robust III trial has studied the effect of a drug-coated
balloon (DCB), namely the Optilume® with a Paclitaxel coating among an adult
population with stricture ≤12Fr in diameter and ≤3 cm in length, having at least
two prior endoscopic treatments, and IPSS ≥11 and maximum ow rate <15mL per
second. The study showed signicant improvement at 6months in the treated group
compared to the control with values of 75% and 27% respectively [38]. Despite
yielding encouraging results, the authors concluded that the Optilume® DCB should
serve merely as an alternative for men who had an unsuccessful direct vision internal urethrotomy/dilation and who want to avoid or delay urethroplasty which
remains the best denitive treatment.
32.6.1.2 Tissue Engineering
Various matrices have been proposed for urethral mucosa replacement including
small intestinal submucosa grafts, bladder-derived matrices (collagen-based and
acellular bladder matrix), acellular dermis graft, etc. However, although promising,
the results are still not proportionate to the enthusiasm raised in the last decades, and
3D-bioprinting to manufacture patient-tailored designs of seeded tubular urethral
constructs is still in the dreamworld, but boundless human genius has yet to say its
last word [39].
The development of autologous tissue-engineered buccal mucosa has been rst
introduced in 2004 from a small buccal mucosa specimen (0.5cm) [40], and its
initial clinical application was tried in 2008 with encouraging results as 3 patients
out of 5 had a patent urethra after a mean follow-up of 33.6months [41].
A German pharmaceutical company (UroTiss Europe GmbH) has further developed the idea and is manufacturing an autologous tissue-engineered oral mucosa
graft as MukoCell®. This was studied in a multicenter and prospective trial
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32 Treatment ofUrethral Injury. II: TheAnterior Urethra
recruiting 99 patients, showing encouraging success rates in terms of improvement
of peak ow rate (Qmax) of 67.3% and 58.2% at 12-month and 24-month followup, respectively, but the results were signicantly dependent on the surgeon experience [42].
References
1. Chapple C, Barbagli G, Jordan G, Mundy AR, Rodrigues-Netto N, Pansadoros V.Consensus
statement on urethral trauma. BJU Int. 2004;93:1195–202.
2. Rourke KF, Jordan GH. Primary urethral reconstruction: the cost minimized approach to
the bulbous urethral stricture. J Urol. 2005;173(4):1206–10. https://doi.org/10.1097/01.
ju.0000154971.05286.81. PMID: 15758749.
3. Blaschko SD, Harris CR, Zaid UB, Gaither T, Chu C, Alwaal A, McAninch JW, McCulloch
CE, Breyer BN.Trends, utilization, and immediate perioperative complications of urethroplasty in the United States: data from the national inpatient sample 2000-2010. Urology.
2015;85(5):1190–4. https://doi.org/10.1016/j.urology.2015.01.008. Epub 2015 Mar 4. PMID:
25746579; PMCID: PMC4917203.
4. Nilsen OJ, Holm HV, Ekerhult TO, Lindqvist K, Grabowska B, Persson B, Sairanen J.To
transect or not transect: results from the Scandinavian urethroplasty study, a multicentre randomised study of bulbar urethroplasty comparing excision and primary anastomosis
versus buccal mucosal grafting. Eur Urol. 2022;81(4):375–82. https://doi.org/10.1016/j.
eururo.2021.12.017. Epub 2022 Jan 8. PMID: 35012771.
5. Bugeja S, Andrich DE, Mundy AR.Non-transecting bulbar urethroplasty. Transl Androl Urol.
2015;4(1):41–50. https://doi.org/10.3978/j.issn.2223- 4683.2015.01.07. PMID: 26816808;
PMCID: PMC4708276.
6. Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M.Current controversies in reconstructive surgery of the anterior urethra: a clinical overview. Int Braz J Urol. 2012;38(3):307–16;
discussion 316. PMID: 22765862. https://doi.org/10.1590/s1677- 55382012000300003.
7. Ozgök Y, Ozgür Tan M, Kilciler M, Tahmaz L, Erduran D. Use of bladder mucosal
graft for urethral reconstruction. Int J Urol. 2000;7(10):355–60. https://doi.org/10.1046/
j.1442- 2042.2000.00210.x. PMID: 11144502.
8. Gelman J, Furr J.Tissue transfer techniques in the management of urethral stricture disease:
aps and grafts. In: Martins FE, Kulkarni SB, Köhler TS, editors. Textbook of male genitourethral reconstruction. Cham: Springer; 2020. https://doi.org/10.1007/978- 3- 030- 21447- 0_7.
9. Filipas D, Wahlmann U, Hohenfellner R.History of oral mucosa. Eur Urol. 1998;34(3):165–8.
https://doi.org/10.1159/000019705. PMID: 9732186.
10. Korneyev I, Ilyin D, Schultheiss D, Chapple C.The rst oral mucosal graft urethroplasty was
carried out in the 19th century: the pioneering experience of Kirill Sapezhko (1857-1928).
Eur Urol. 2012;62(4):624–7. https://doi.org/10.1016/j.eururo.2012.06.035. Epub 2012 Jun 27.
PMID: 22749735.
11. Humby G.A one-stage operation for hypospadias. Br J Surg. 1941;29:84–92.
12. el-Kasaby AW, Fath-Alla M, Noweir AM, el-Halaby MR, Zakaria W, el-Beialy MH.The
use of buccal mucosa patch graft in the management of anterior urethral strictures. J Urol.
1993;149(2):276–8. https://doi.org/10.1016/s0022- 5347(17)36054- 8. PMID: 8426400.
13. Morey AF, McAninch JW.When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology. 1996;48(2):194–8. https://doi.org/10.1016/S0090- 4295(96)00154- 9. PMID:
8753728.
14. Barbagli G, Balò S, Sansalone S, Lazzeri M.How to harvest buccal mucosa from the cheek.
Afr J Urol. 2016;22(1):18–23. https://doi.org/10.1016/j.afju.2015.09.001. issn:1110-5704.
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