Management of anterior urethral strictures with buccal mucosa: Our pioneering experience

African

Journal

of

Urology

Official

journal

of

the

Pan

African

Urological

Surgeon’s

Association

web

page

of

the

journal

www.ees.elsevier.com/afju www.sciencedirect.com

Review

Management

of

anterior

urethral

strictures

with

buccal

mucosa:

Our

pioneering

experience

Abdelwahab

Elkassaby

,

Mohamed

Kotb

DepartmentofUrology,FacultyofMedicine,AinShamsUniversity,Egypt

Received21January2016;accepted25January2016 Availableonline2March2016

KEYWORDS

Anteriorurethralstrictures;

Urethroplasty;

Buccalmucosagraft

Abstract

Urethralstricturemanagementisachallengingsurgery.Multiplicityoftechniquesmeansthatnoneofthem isideal.Nosingletechniqueisappropriateforallsituationsandthesuccessfulsurgeonshouldhaveastore ofoperationstochoosefromaccordingtoeachspecificcase.Thisreviewaimstoprovideanupdateonthe differentusesofbuccalmucosalgraftasareconstructiveandreplacementtoolforanteriorurethralstrictures management.

©2016PanAfricanUrologicalSurgeons’Association.ProductionandhostingbyElsevierB.V.Allrightsreserved.

Historicalbackground

Buccalmucosagraft(BMG)wasfirstuseasaurethralreconstructing toolbyHumbyin1941.Heusedalowerlipgraftforapatientwith multiplehypospadiasrepairpresentedwithpenoscrotalfistula[1]. Thiswasfollowedbyalongperiodofinactivity.

In1978,westartedusingbuccalmucosalgraftsformanagement ofcrippled hypospadias.Preliminaryresultswere not encourag-ing.ThefirstpublishedserieswerebyBurgeretal.,in1992,who describedtheuseofbuccalmucosalgraftinsixpatients;threeof themwithpriorfailedhypospadiasrepairandshortageofgenital

∗_{Correspondingauthor.}

PeerreviewunderresponsibilityofPanAfricanUrologicalSurgeons’ Association.

skin[2].Againtheresultswereunsatisfactorytill1995,when Duck-ettetal.successfullyusedbuccalmucosaforurethralreconstruction afterhypospadias,epispadiasandurethralstrictures[3].

In 1993, El-Kassabyetal. publishedthe first seriesforanterior urethralstricture repair usingbuccalmucosal grafts.20 patients underwent1-stagecorrectionofananteriorurethralstrictureusing a buccalmucosapatch graft.This techniquewas usedforshort strictures(1–2cm)thatusuallyrequireda2–4cmrepair.Results weresuccessfulin18patients,while2redosurgeryforrecurrent stricture[4].

Anatomicandhistologicconsiderations

Theoralmucosaisthemucousmembraneliningtheinneraspect ofthemouth.Ithastwomajorlayers,namelytheepitheliumand theunderlyingconnectivetissue(termedlaminapropria).Another http://dx.doi.org/10.1016/j.afju.2016.01.003

Masticatorymucosaisformedofkeratinizedstratifiedsquamous epithelium,found on thedorsum of thetongue, hardpalateand attachedgingiva.Itsstructureallowsittoresisttheabrasionofrough foodparticles.

Lining mucosa is formed of nonkeratinized stratified squamous epithelium,foundalmosteverywhereelseintheoralcavity, includ-ingbuccal,labialandalveolarmucosa[5,6].

• Buccalmucosareferstothemembraneliningoftheinner sur-faceofthecheeksfromthelineofcontactoftheopposinglips anteriorlytothelineofthepterygomandibularraphe(lateralto retromolartrigone)posteriorly.Themedialboundaryisthelineof attachmentofthebuccalmucosatotheupperandloweralveolar ridgessuperiorlyandinferiorly.Itconsistsofstratifiedsquamous epithelium(oralepithelium)andanunderlyingconnectivetissue (laminapropria)[7].

• Labialmucosareferstotheinsideliningofthelips.

• Alveolarmucosareferstothemucosabetweenthegumsandthe buccal/labialmucosa.

Specializedmucosafoundspecificallyintheregionsofthetastebuds onlingualpapillaeonthedorsalsurfaceofthetonguethatcontains nerveendingsforgeneralsensoryreceptionandtasteperception [5,6].

Anteriorurethralstrictures

Theanteriorurethralstrictureequalsnarrowingoftheanterior ure-thra.Thepathologyisexplainedmainlybyfibrosisandscarringof theurethralepitheliumtogetherwiththespongyerectiletissueof corpusspongiosum[8].

Etiologyofanteriorurethralstrictures

Toomanycausesparticipateinthisprocess.Infection,traumaand lichensclerosisareconsideredasthemostcommonetiologies. How-ever,mostcausesofurethralstricturesremainunknown,butthey areprobablyduetoaremoteunrecognizedperinealtraumaor recur-rentattacksofurethralmildinfections(asNeisseriagonorrheaor Chlamydia)[9].

Thepathologicalprocessincludesinjurytotheurethralepithelium ortheunderlyingcorpusspongiosumleadingtohealingbyascar whichendsbyananteriorurethralstricture.Trauma,usually strad-dle,eitherpresentsasacuteretentionandurethralbleeding,ormore oftengoesunrecognizedandpresentslaterwithobstructive void-ingcomplaints.Iatrogenictraumatotheurethracouldbethecause, ascatheterizationandendoscopicprocedures,butitdecreaseswith finemanipulationoftheurethra[10].

Lichensclerosusetatrophicusisanothercommonchronic inflam-matory conditionthat affectsthe anteriorurethra as wellas the foreskinandglans.Itisconsideredasafrequentcauseofphimosis, meatalstenosisandlonganteriorstrictures.

Lichensclerosischaracterizedwithuncertainetiology,varied pre-sentation,andmultipletreatments.Inearlystages,ashortcourseof steroids,topicalorsystemic,cancontrolthediseaseandprevent progression.Surgical treatmentby circumcision canbecurative ifthe diseaseistreatedearlywhenstilllocalized.Progressionto longsegmentstrictureorpanurethralstricturewillnecessitatemore sophisticatedmanagement[12].

Presentationofurethralstricturepatients

Thesepatientsusuallypresentwithlowerurinarytractobstructive symptomsorrecurrenturinarytractinfectionssuchasprostatitis orepididymitis.Somepatientsalsopresentwithurinaryretention. Butwithdetailedhistory,mostofthesepatientsarefoundtohave toleratednotablevoidingobstructivesymptomsforalongperiodof timebeforeprogressingtocompleteobstruction[10].

Evaluationofanteriorurethralstrictures

Tostart treatment, the natureof the stricture includingstricture anatomyshouldbeaccuratelydetermined.Thelocationandlength ofthestrictureisdeterminedusingradiography[13],urethroscopy, flexiblecystoscopy[14]andultrasonography[15].Thedepthand densityofthescarinthespongytissueismoredifficulttoestimate butitcouldbemeasuredbyultrasonographyormagneticresonance imaging.MoreyandMcAninchfoundthatultrasonography accu-ratelydefinestheextentofspongiofibrosisinbulbarurethra[15].It usuallyexceedstheappearanceofthestricturelengthmeasuredin thecontraststudies.Itisverybeneficialforreconstructiveurologists toattendtheurethrographyordoingitbythemselves.

Evenbytheuseofallofthesetools,thefinalandmostaccurate evaluationofstricturewillbeavailableduringsurgeryassistedby antegradeorretrogradeendoscopy.

Managementofanteriorurethralstrictures

Ithasbeensaidthatthereisnotissuebetterthantheurethratoreplace the urethra. Thisis trueforshort stricturein the bulbar urethra amenableforexcisionandprimaryanastomosis.Butthisis how-evernotpossibletoachievewithlongerstricturestoavoidtherisks ofexcessivemobilizationandpenilecurvature.That’swhy urolo-gistsshouldbefamiliarwiththeuseofmanysurgicaltechniquesto dealwithanyconditionoftheurethraduringsurgery.

Amongthesetechniques,penilegraftshavebeenusedtoreconstruct theurethrainthosestrictures.Toimprovethesurvivaland vascu-larity,theuseoflocalflapshasalsobeenadvocated.Flapshowever aretechnicallydemanding,andarenotsuitableincasesofLichen Sclerosis.

Inpursuit forthebestgraftmaterial,bladdermucosaandbuccal mucosalgraftshave been used. The useof the latter hasmany advantages[4,16].

Figure1 AugmentedRussellTechniqueshowingclosureoftheroofusingbuccalmucosalgraftafterexcisionofstricturedsegment[18].

Treatmentoptionsforanteriorurethralstrictures

Differenttreatmentoptionsareavailableformanagementof ante-riorurethralstricturesdependingonstricturesiteandlength.This includes:

1. Excisionwithpartial anastomosis:Heusner,Dugas,Hamilton Russell.

2. Excisionwithprimaryanastomosis:Heitz,Boyer,Marion. 3. Stagedrestoration.

4. Flapreconstruction.

5. Graftreconstruction(Skin,BladderandBuccal) 6. Recently:tissueculture,acellularmatrices.

Augmentationandsubstitutionurethroplasty

Excisionwithpartialanastomosis Heusner,Dugas,HamiltonRussell

Theuseofexcisiontechniquesinthetreatmentofurethralstrictures wassummarizedbyHamiltonRussellin(1915).Thesetechniques arenotpreferredbymanysurgeonsbecausefurtherstricture forma-tiongavedisappointinglong-termresults[17].

In2007,El-Kassabyandcolleaguespresenttheir10-yrexperience withone-stagerepairoflongbulbarurethralstricturesusing aug-menteddorsal strip anastomosis in >234 cases. Bulbarurethral strictureshadameanof4.2cmofwhichameanof2.8cmdiseased urethralsegmentwasincised.Followedbyexcisionofmostofthe fibrosedspongiosum,suturingoftheroof(Russell)andgraftingthe floorwithBuccalmucosalgraft.Theoverallsuccessrateexceeded 93%[18](Fig.1).

Ventraldefectin“AugmentedRussel DorsalstripAnastomosis” couldbecoveredusingfreegraftofnonhirsutegenitalskin,buccal mucosa,bladdersubmucosa,orabipedicledpenileskinflap(Fig.2).

Excisionwithprimaryanastomosis Heitz,BoyerandMarion

AppliedbyMarionin(1912)andHeitz-Boyerin(1922),excision ofthestenosedsegment,end-to-endanastomosis,andsuprapubic cystostomyimprovedthesuccesswithstricturesurgery.In1975,

TurnerWarwickreportedexcellentresultsofanobliqueend-to-end anastomosisinthebulbousurethra[17].

Stagedrepairtechniques

Stagedrepairoflongbulbarurethralstricturesisoneoftheoldest formsofurethralreconstruction.Multistagereconstructioninvolves exposureoftheurethratotheoutsidewithorwithoutexcisionand grafting.3–12monthslater,aftertheinflammationsettlesdownand thegraftbecomeswelltaken,thedefectisclosed.

In1911,HamiltonRussellusedexternalurethrotomyfortherelief oflongrecurrenturethralstricturesespeciallyanteriorurethral stri-ctures.Heincisedtheurethraforthewholelengthofthestricture andthensuturedtheedgesoftheurethratotheadjacentskin,thus creatinganartificialhypospadius[17].

An extension ofthe Hamilton Russeltechnique,the buried-skin techniquewasintroducedbyDenisBrownein(1949).DenisBrowne establishedthatastripofpenileskinwouldinevitablyformatube ifleftinsituandburiedbyclosingtheskinoverit.

JohnSwinney(1952)excisedthestrictureandallscartissueand thenclosedtherawareawithadjacentskin.Thesecondstagewas aTheirsch-Duplay[17].

Recently,stagedrepairislimitedtosomespecificindications.This includesstricturesassociatedwithchronicinflammation,previous recurrentinfectionsorabscess,radiation,spinalcordinjuries, fis-tulas,false passages, urethral diverticula, and failed priorrepair [19].

Stagedrepairincludesexcisionofunhealthytissuesfollowedby bridgingofthedefectbyagraftandlatertubularization[20](Fig.3). WeuseFull-thicknessskingrafts(FTSG),Split-thicknessskingrafts (STSG)orbuccalgraftsintheseprocedures.

Flapreconstruction

Thefirstdescriptionofanislandofskinwithanaxialbloodsupply usedforurethralreconstructionwasbyDuckettein1980[21].

Figure2 “AugmentedRusselDorsalstripAnastomosis”showingaugmentationoftheventralfloordefectusingventral penileflap.

Figure3 Secondstagerepairoflongurethralstricturefollowingfirststagebuccalmucosalgrafting.

Quartey(1983)describedasimilartechniqueusingtheflapto recon-structtheurethrafollowingstricturesanywherefromtheexternal meatustotheprostaticurethra[22].

Graftreconstruction Skingrafts

Since(1953)PresmanandGreenfield,usedpreputialskingraftto manageabulbarurethralstricture[23].LaterDevineandHorton popularizedthetechniqueusingfreefullthicknesshairlessskingraft toreconstructtheurethrainaone-stagerepairofhypospadias[24]. Extrapenilefullthicknessskinhasnotbeenapopulargrafttissue forurethralreplacementduetosuboptimalresults[25].

Barbaglietal.(1996),followingtheconceptadvocatedbyMonseur, introducedthe dorsallyplaced graft.Itallowsbettermechanical supportforthegraft withanadequatevascular bedforthegraft fromtheunderlyingcorporealbodies[26].

Twomaintypesofskingraftsareavailableaccordingtothethickness ofgrafttaken;split-thicknessandfullthicknessskingrafts. split-thicknessgraft (STG)includesthe epidermis andthe superficial dermal(intradermal)plexus.Afull-thicknessgraft(FTG)includes theepidermis, the superficialdermisand the deepdermis. They aremoredurableanddoesnotcontractasSTG.Extragenital full-thicknessskingraftscarryincreasedmass,whichgenerallymakes themmorefastidiousthangenitalfull-thicknessgrafts(i.e.,preputial andpenileskingrafts)[27].

Bladderepithelialgraft

Memmelaar(1947)wasthefirsttoreporttheuseofbladder epithe-liumforurethralreconstruction[28].

Bladderepitheliumhasbeenanattractivematerialforconstruction oftheneourethrainrepeatrepairsofhypospadiasandother com-plexurethralanomalies.Theytendtohavemorefavorablevascular

Figure4 Lowerlipbuccalmucosalgraft.

characteristics.Itisaccustomedtoexposuretourine,resists shrink-age,andisreadilyavailableinadequateamounts[29].

Therewasa highincidenceofmeatalproblems withthe useof bladderepitheliumasaurethralsubstitute.Theexposedepithelium behavessimilartotheexstrophybladderepithelium,which hyper-trophies,becomessticky, andeventually metaplastic.Itdevelops mucin-secretingglands, leadingto prolapseand/or stenosis[30]. Weavoidedthisinourongoingseriesofpanurethralstricturerepair followingLichensclerosis.Ourtechniqueincludestheproximaluse ofbladdermucosaandthedistalrepairusingbuccalmucosalgraft withniceresultsyet.Futurestudiesshouldtakeinconsiderationthat randomizationisnotpossiblebecausedifferenttechniquesarenot suitableforallcases.

Buccalmucosalgraft

Advantagesofbuccalmucosalgrafts. Variousfactorshave con-tributedtotheacknowledgementofbuccalmucosalgrafts(BMGs) asanidealsubstituteforthe urethra,includingeasyaccessibility andmanualhandling,resistancetoinfection,compatibilitywitha wetenvironment,athickepitheliumandathinlaminapropria,and favorablegrafthostvascularrelationshipallowingearly inoscula-tion.

Buccalmucosalgrafthasa‘panlaminarplexus’,whichprovides optimalvasculartake[27].

Thebuccalmucosapatchgraftishairlessandcantoleratetrauma andinfectionadequatelywithhighpowerofregeneration[4]. Theoralmucosaalsoprotectsthehostagainstinvadingpathogens throughtoughlaminapropriathatprovidesresistancetotearforces andprotectagainstmicroorganisms.Thisprotectionfrom microor-ganismsisalsoduetocellsheddingfromthesurfacelayer,therefore minimizingcolonization.Theoralmucosa containsacompetent immunesystemkeepingtheoralmucosainahealthystatedespite theheavymicrobialloadusuallyfoundintheoralcavity[31,32]. Buccalmucosadiffersfromintestinalmucosainthatitdoesnothave anadsorptivecapacity,althoughdifferencesinpermeabilityexistin directcorrelationtothethicknessoftheepithelialbarrier[5,33]. Surgicaltechnique

1. Graftharvest 2. Position

3. UrethroplastywithBuccalMucosalGraft(Exposure, Mobiliza-tion,Graftplacement,Closure,Post-operativecare).

Harvestingofbuccalmucosalgraft Donorsite

Atthebeginningofourexperience,westartedbyharvestingalower lipgraftthenshiftedtocheekoneortwosides(Fig.4).NowLip

Figure5 Dingmanmouthgagwith3bladesforcheekbuccalmucosal graftharvesting.

graftsarelimitedtolongstrictures,ifneeded,togetherwithbilateral cheekgraft.Werarelyuselingualmucosa.

Technique

The technique of harvesting the graft has been variable; some authorspreferharvestofthegraftbeforeexposingthestrictureto shortenthetimeinlithotomyposition[34].

Ourpreferenceisthe2-teamapproach.Thisdecreasesthetimingof thesurgerybutitneedsproperdecisionmakingbeforethesurgery. Generalanesthesiabynasalintubationispreferred.Followedby sterilizationanddrapingoftheoralcavityandtheperinealfieldin thesametime.Sterilizationofthemouthusingchlorhexidineand Betadinefortheperioralarea.

WealsopreferusingtheDingmanmouthgagwith3blades(Fig.5). Othersimplermouth retractorsare alsoavailable. Thiscouldbe helpedbysomestayand/orevertingsuturestothelipsifneeded. Stensenductismarked.Alsothegraftismarkedonthecheekand/or the lower lip.A mixtureof lidocaine and epinephrine couldbe injectedalongthelateralbordersofthegraft tostretchthegraft anddecreasebleeding.

Thegraft is separatedfrom theunderlying buccinatorwithcare to avoid deeper dissectionin the muscle wherethe branches of neurovascularplanelies.

Thedonorsiteisinspectedforhemostasisusingbipolarcauteryand epinephrinesoakedgauzesarelefttostayforfewminuteswhilethe

Figure6 CompletePerineopenileDegloving.

graftisdefattened.Thegraftisheldforde-fatteningasthishelps thegrafttakeattherecipientsite.

Thegraftishandedtotheurethraltraytable,andthedonorsiteis closedusingcontinuous3-0vicryl.Theepinephrinesoakedcottonis leftatthedonorsitewhichwillberecheckedattheendofthesurgery beforedischargetorecovery.Somesurgeonspreferonlyhemostasis forthegraftwithsomeedgesutureswithoutapproximatingthetwo opposingedges.Thisispreferredinwidegraftsespeciallyfromthe lips.

Weuseanantibioticsolutiontosoakthegraftafterharvest.

Patientpositioning

In Ain ShamsUniversity, weaccess to the perineumthrough a lowlithotomy positionwhilesome surgeonspreferthe exagger-atedlithotomy[35].Compartmentsyndromeismorefrequentin thelowlithotomyposition,thisresultfromcalfcompression lead-ingtodecreasedvenousoutflowandincreasedpressurewithinthe legcompartmentsresultingindecreasedarterialinflowandischemic injury.Sopressureonthecalfmusclesespeciallybytheassistant surgeonshouldbeavoided.

Urethroplastyusingbuccalmucosalgraft Exposure

Shortanteriorurethralstricturescouldbemanagedthroughapenile deglovingincisionfollowedbyurethralmobilizationandpenileskin graft.

Forlongerstrictures,especiallythoseduetolichensclerosisorwith deficientnon-hirsutepenileskin,buccalmucosacouldbeusedwith differentincisionapproach:

Perinealincision:alambdashapedincisionissharplyoutlinedin theperineum(somesurgeonspreferalongitudinalincision) Kulkarnietal. describedin 2000anew,fulllength(penile and bulbar),one-stageoralmucosalgrafturethroplastyinpatientswith panurethralstricturesduetolichensclerosus[36].

Ourtechniqueformanagementofsuchstricturesincludesperineal incisiontogetherwithanothersubcoronalpeniledeglovingincision. Thisallowsfullpenileretrievalthroughtheperineuminwhatwe call“CompletePerineopenileDegloving”(Fig.6).Thistechnique offerseasierrepairofpanurethralstricturedowntothemeatus.

Figure7 Theurethraisexposedbyretractionoftheischiocavernosus muscles.

Mobilization

Dissectioniscarrieddowntothemidlinefusionofthe ischiocaver-nosusmuscles,whichiscompletelyseparatedfromthespongiosum (Fig.7).

Thecorpusspongiosumisdetachedfromitsbondtotheperineal body,andtheproximalbloodsupplyisdivided.Thedissectionis carriedproximallyasfarasthemembranousurethra(Fig.8). Distallythe corpus spongiosum is detached from the triangular ligamenttothemidscrotallevel,andseparatedfromthecorpora cavernosa,withexcisionofpartsofBuck’sfascia(Fig.9). In 2009, Barbagli modified his own technique [37]; combining theuseofmuscleandnervesparingbulbarurethroplastywiththe fulllengthdorsalurethralopeningfromKulkarni’stechnique.This offerspreservationofthelateralvascularsupplytotheurethra,the centraltendonoftheperineum,thebulbo-spongiosummuscleand itsperinealinnervations[38].

Graftplacement Dorsalgrafting

Theproximalendofthestrictureislocalizedusingcautious ante-gradepassageofcurvedurethralmetaldilator.Thisisveryimportant especiallyinlongstricturesreachingthemembranousorproximal

Figure8 Theurethramobilizedfromthecorporaandfromthe peri-nealbody.

Figure9 Distaldissectionoftheurethra.

bulbararea.Anothermethodincludestheuseofantegradeflexible cystoscopy.

Localizationofthedistalsegmentisusuallybylargecaliberneleton plasticcatheter.Thisgoalcouldbealsoachievedusingretrograde urethroscopy.Alsosterilemethyleneblueinjectioninthedistalend willgivebetteridentificationofthehealthymucosaespeciallyin longstrictures.

Thelimitofthestrictureismarkedontheurethraandusingasharp scalpeltheurethraisopeneddorsally.Urethralstrictureiseither inciseddorsallyifthestricturecaliberiswideoritisexcised.The edgesarecheckedanddébridedofanyfibroustissue,theurethra isthenspatulateddorsally. Thegraft isthenspread fixedto the triangularligamentandcorporacavernosa.

Thegraftismeshedusingasharpscalpelthentheedgeofthegraftis suturedtothespatulatedurethra.Theflooroftheurethrais reapprox-imated.Thisisdonebyholdingthe2lateralendstogetherby3-0

PDSavoidingepithelium,thenepitheliumisclosedby6-0Vicryl andthecorpusspongiosumissuturedtogetherby4-0PDS.Also somesurgeonsprefersuturingfullthicknessurethralwallinstead ofdoublelayeredsuturing.

Thelateraledgesofthestricturotomyarethensuturedtothegraft using4-0Vicrylthuscompletingtheonlay(Fig.10).

Ventralgrafting

Theurethraisopenedventrally.Theurethraisthespatulated ven-trally.

Thegraftisthenplacedandmeticulouslysewntotheepithelium. Withthegraftinplacethebulkofthecorpusspongiosumisthen suturedtothegrafttobeginthespongioplasty.Thiswilladd bet-tergraft revascularizationand “Take”.Finallytheadventitiaand theremainingbulkofthecorpusspongiosumaresuturedbyPDS sutures.

Ventral,dorsalorlateralgrafts

Thedorsalonlayprocedureforbulbarstricturesgotsome advan-tagesovertraditionalventralonlayurethroplasty.Fixingthegraft totheundersurfaceofthecorporalbodiesappearstoprovideboth anexcellentbloodsupplyandgoodmechanicalsupport,reducing shrinkage,chordeeformationandventralgraftsacculation[26]. Lat-eralgraftingalsoprovidesminimalunilateraldissectionandshould betakeninconsiderationinsomecases.Thethreeapproaches; ven-tral,dorsalorlateral[39]graftpositioning,hasprovidedthesame successratesandstricturerecurrencerate[40].

Urethralsubstitutionwithbuccalgraft

Inlongstrictures,ifinvolvingthepenileurethraandcausingpenile curvature,thepenileurethrashouldbeexcisedandtotallyreplaced bybuccalmucosalgraftasafirststagerepairthenretubularization ofthe graftin the secondstagebecausetube replacementisnot recommendedanymore.Thisisaformofsubstitutionurethroplasty. Incaseof“Multistageurethroplasty”ofthepenileurethrabybuccal graft,careshouldbetakentofacilitatereconstructionofthebedof theappliedgraftsbyputtingthepeniledartosinthelateralpartsof theappliedgrafts.Sothegraftshouldnotbeapplieddirectlyonthe tunicaalbugineaofthepenilecorpora.Thewillfacilitatesthefuture tubularizationofthetakengraftsinthesecondstagefromthelateral sides.

Closure

Foleysiliconurethralcatheterispassedbeforeclosingthe anasto-mosis.Itshouldbeofsmallercaliberthantheneletoncatheterused forrepair.Hemostasisisreassuredthenclosureofwoundinlayers leavingsmallcalibersuctiondrain.

Postoperativecare

1. Patientremainsinbedrestforthefirst48hthenallowed ambu-latingwithassistance;activityislimitedtowalkingandreclining inthebedwithnoprolongedsitting.Thepatientisadvisedto maintainmildactivitytillthecathetersareremovedin4weeks.

Figure10 Urethraldorsalgraftingwithbuccalmucosalgraftforlongpenileurethralstrictureduetolichensclerosis.

Figure11 Theofacellularcollagenmatrixgraftingasanofftheshelfengineeredtissueinmanagementofurethralstrictures.

2. Dietisallowedastoleratedwithnorestrictions,stoolsofteneris givenfor10days.Oralgelcouldbeusedandcoldsoftfoodtill healingoforalgraftbed.

3. AntibioticcoveringgramnegativeorganismisgivenIVfor48h thenthepatientisstartedonsuppressivetherapyfor4weeks. 4. Neurovascularchecksforcompartmentsyndrome, as wellas

DVTandatelectasisprophylaxisistakenintoaccount. 5. In4weeksthepatientreturnsforthevoidingtrialafterremoval

of the urethralcatheter. The suprapubic tubeis plugged and removedin2days.

6. After voidingtrial, they werefollowed up at3months with uroflowmetry,retrogradeurethrogram(RGU).

7. Patientswerefurtherfollowed-upwithuroflowmetryat3months intervalandRGUevery6monthsintervalforthefirst2years. Andlateronifneeded

Recurrentstrictures

Theidealtherapyforrecurrentstrictureafteropenurethroplastyhas notbeenestablished.Repeaturethroplastyisfrequentlyacomplex andlengthyprocedures.

Flaps are preferredfor substitutionurethroplastybecauseof the theoreticaladvantagethattheycarrytheirownbloodsupplyleading

tobetterviabilitychances.Recently,therehasbeenatrendtoward grafts,particularlybuccalmucosalfreegrafts.

Buccalmucosacouldbeusedinprimaryandsalvage urethroplas-ties,asdorsalonlay,ventralonlay,andastubedgraftsinurethral strictures.Thebuccalgraftisanexcellentandavailablesourceof materialforurethralreplacementincomplexurethroplasties. Multistageproceduresmayrepresentabetterchoiceinrepeated ure-throplastiesespeciallyinthepresenceofseverefibrosisorrecurrent nearinfections.

Thefutureofanteriorurethralstricturesurgery

Thefutureofanteriorurethralsubstitutesseemsto lieon Tissue Engineering.Acellularcollagenmatrixgraftingasanofftheshelf engineeredtissuewasintroducedbyElkassabyetal.in2003[41]. Thiswillobviatetheneedfortissuetransferinpatientswithlong andcomplexstrictureswithnolimitationsasregardsthequantityor qualityofurethralsubstitutesavailableinanygivenpatient(Fig.11). Goodprimitiveresultsareavailablebutlongtermfollowuptogether withcostcontrolarestillneeded.Nowadays,itisunclearwhether cellseedingcouldbeanadvantageinthenearbyfuture.

Conflictofinterests None.

Funding None. References

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