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Substitution Urethroplasty for Bulbar Urethral Strictures

  • Akio HoriguchiEmail author
  • Masayuki Shinchi
Chapter

Abstract

Open surgical repair using free grafts or pedicled skin flaps, called substitution urethroplasty, is the gold standard procedure for bulbar urethral strictures not suitable for excision and primary anastomosis. Buccal mucosa harvested from the inner cheek is an ideal urethral substitute and is the tissue most often used for substitution urethroplasty because of its compatibility with urethral tissue, the ease of harvesting and handling it. Since the start of widespread use of the buccal mucosa graft in substitution urethroplasty, the use of pedicled skin flaps have become less common. Most bulbar urethral strictures can be repaired by one-stage urethroplasty, and buccal mucosa graft onlay augmentation is the most preferred procedure. Onlay augmentation on the ventral side (ventral onlay) or dorsal side (dorsal onlay) has been widely used, and other options are dorsal inlay with ventral sagittal urethrotomy or lateral onlay with one-sided urethral dissection. The success rate is the same for the different graft positions. In bulbar urethral strictures with obliterative or nearly obliterative segments, either a two-sided dorsal plus ventral onlay augmentation or a combination of excision and primary anastomosis and onlay augmentation (augmented anastomotic urethroplasty) is the procedure of choice. In this chapter, a practical strategy of substitution bulbar urethroplasty mainly using buccal mucosa graft is described.

Keywords

Bulbar urethra Urethral stricture Urethral substitute Substitution urethroplasty Buccal mucosa 

References

  1. 1.
    Alwaal A, Blaschko SD, McAninch JW, et al. Epidemiology of urethral strictures. Transl Androl Urol. 2014;3:209.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Latini JM, McAninch JW, Brandes SB, et al. SIU/ICUD consultation on urethral strictures: epidemiology, etiology, anatomy, and nomenclature of urethral stenoses, strictures, and pelvic fracture urethral disruption injuries. Urology. 2014;83:S1.Google Scholar
  3. 3.
    Mundy AR, Andrich DE. Urethral strictures. BJU Int. 2011;107:6.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Lumen N, Hoebeke P, Willemsen P, et al. Etiology of urethral stricture disease in the 21st century. J Urol. 2009;182:983.Google Scholar
  5. 5.
    Palminteri E, Berdondini E, Verze P, et al. Contemporary urethral stricture characteristics in the developed world. Urology. 2013;81:191.Google Scholar
  6. 6.
    Liu JS, Hofer MD, Oberlin DT, et al. Practice patterns in the treatment of urethral stricture among American urologists: a paradigm change? Urology. 2015;86:830.PubMedGoogle Scholar
  7. 7.
    Buckley JC, Heyns C, Gilling P, et al. SIU/ICUD consultation on urethral strictures: dilation, internal urethrotomy, and stenting of male anterior urethral strictures. Urology. 2014;83:S18.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Morey AF, Watkin N, Shenfeld O, et al. SIU/ICUD consultation on urethral strictures: anterior urethra – primary anastomosis. Urology. 2014;83:S23.Google Scholar
  9. 9.
    Andrich DE, Mundy AR. Non-transecting anastomotic bulbar urethroplasty: a preliminary report. BJU Int. 2012;109:1090.Google Scholar
  10. 10.
    Jordan GH, Eltahawy EA, Virasoro R. The technique of vessel sparing excision and primary anastomosis for proximal bulbous urethral reconstruction. J Urol. 2007;177:1799.Google Scholar
  11. 11.
    Lumen N, Poelaert F, Oosterlinck W, et al. Nontransecting anastomotic repair in urethral reconstruction: surgical and functional outcomes. J Urol. 2016;196:1679.Google Scholar
  12. 12.
    Chapple C, Andrich D, Atala A, et al. SIU/ICUD consultation on urethral strictures: the management of anterior urethral stricture disease using substitution urethroplasty. Urology. 2014;83:S31.PubMedGoogle Scholar
  13. 13.
    Andrich DE, Dunglison N, Greenwell TJ, et al. The long-term results of urethroplasty. J Urol. 2003;170:90.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Eltahawy EA, Virasoro R, Schlossberg SM, et al. Long-term followup for excision and primary anastomosis for anterior urethral strictures. J Urol. 2007;177:1803.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol. 2002;167:1715.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Morey AF, Kizer WS. Proximal bulbar urethroplasty via extended anastomotic approach – what are the limits? J Urol. 2006;175:2145.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Mundy AR. Anastomotic urethroplasty. BJU Int. 2005;96:921.Google Scholar
  18. 18.
    Terlecki RP, Steele MC, Valadez C, et al. Grafts are unnecessary for proximal bulbar reconstruction. J Urol. 2010;184:2395.Google Scholar
  19. 19.
    Barbagli G, De Angelis M, Romano G, et al. Long-term followup of bulbar end-to-end anastomosis: a retrospective analysis of 153 patients in a single center experience. J Urol. 2007;178:2470.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Palminteri E, Berdondini E, De Nunzio C, et al. The impact of ventral oral graft bulbar urethroplasty on sexual life. Urology. 2013;81:891.Google Scholar
  21. 21.
    Santucci RA. Substitution urethroplasty or anastomotic urethroplasty for bulbar urethra strictures? Or endoscopic urethrotomy? Opinion: substitution urethroplasty. Int Braz J Urol. 2015;41:613.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Barbagli G, Kulkarni SB, Fossati N, et al. Long-term followup and deterioration rate of anterior substitution urethroplasty. J Urol. 2014;192:808.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Liu JS, Han J, Said M, et al. Long-term outcomes of urethroplasty with abdominal wall skin grafts. Urology. 2015;85:258.PubMedGoogle Scholar
  24. 24.
    Ozgok Y, Ozgur Tan M, Kilciler M, et al. Use of bladder mucosal graft for urethral reconstruction. Int J Urol. 2000;7:355.PubMedGoogle Scholar
  25. 25.
    Palminteri E, Berdondini E, Fusco F, et al. Long-term results of small intestinal submucosa graft in bulbar urethral reconstruction. Urology. 2012;79:695.PubMedGoogle Scholar
  26. 26.
    Simonato A, Gregori A, Ambruosi C, et al. Lingual mucosal graft urethroplasty for anterior urethral reconstruction. Eur Urol. 2008;54:79.PubMedGoogle Scholar
  27. 27.
    Warner JN, Malkawi I, Dhradkeh M, et al. A multi-institutional evaluation of the management and outcomes of long-segment urethral strictures. Urology. 2015;85:1483.PubMedPubMedCentralGoogle Scholar
  28. 28.
    McAninch JW. Reconstruction of extensive urethral strictures: circular fasciocutaneous penile flap. J Urol. 1993;149:488.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Morey AF, Tran LK, Zinman LM. Q-flap reconstruction of panurethral strictures. BJU Int. 2000;86:1039.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Orandi A. One-stage urethroplasty. Br J Urol. 1968;40:717.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Barbagli G, Balo S, Montorsi F, et al. History and evolution of the use of oral mucosa for urethral reconstruction. Asian J Urol. 2017;4:96.PubMedGoogle Scholar
  32. 32.
    Granieri MA, Webster GD, Peterson AC. The evolution of urethroplasty for bulbar urethral stricture disease: lessons learned from a single center experience. J Urol. 2014;192:1468.PubMedGoogle Scholar
  33. 33.
    Dubey D, Vijjan V, Kapoor R, et al. Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial. J Urol. 2007;178:2466.Google Scholar
  34. 34.
    Brandes S, Morey A. Advanced urethral and genital reconstructive surgery: New York: Humana Press; 2013.Google Scholar
  35. 35.
    Morey AF. Re: the use of penile skin graft versus penile skin flap in the repair of long bulbo-penile urethral stricture: a prospective randomized study. J Urol. 2011;186:2298.PubMedGoogle Scholar
  36. 36.
    Dubey D, Kumar A, Bansal P, et al. Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques. BJU Int. 2003;91:215.PubMedGoogle Scholar
  37. 37.
    Lumen N, Oosterlinck W, Hoebeke P. Urethral reconstruction using buccal mucosa or penile skin grafts: systematic review and meta-analysis. Urol Int. 2012;89:387.PubMedGoogle Scholar
  38. 38.
    Wessells H, Angermeier KW, Elliott S, et al. Male urethral stricture: AUA guideline. J Urol. 2016;197:182.PubMedGoogle Scholar
  39. 39.
    el-Kasaby AW, Fath-Alla M, Noweir AM, et al. The use of buccal mucosa patch graft in the management of anterior urethral strictures. J Urol. 1993;149:276.PubMedGoogle Scholar
  40. 40.
    Morey AF, McAninch JW. Technique of harvesting buccal mucosa for urethral reconstruction. J Urol. 1996;155:1696.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Fichtner J, Filipas D, Fisch M, et al. Long-term outcome of ventral buccal mucosa onlay graft urethroplasty for urethral stricture repair. Urology. 2004;64:648.PubMedGoogle Scholar
  42. 42.
    Meneghini A, Cacciola A, Cavarretta L, et al. Bulbar urethral stricture repair with buccal mucosa graft urethroplasty. Eur Urol. 2001;39:264.PubMedGoogle Scholar
  43. 43.
    Wood DN, Allen SE, Andrich DE, et al. The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of nonclosure of the graft harvest site on postoperative pain. J Urol. 2004;172:580.Google Scholar
  44. 44.
    Barbagli G, Fossati N, Sansalone S, et al. Prediction of early and late complications after oral mucosal graft harvesting: multivariable analysis from a cohort of 553 consecutive patients. J Urol. 2014;191:688.PubMedGoogle Scholar
  45. 45.
    Rourke K, McKinny S, St Martin B. Effect of wound closure on buccal mucosal graft harvest site morbidity: results of a randomized prospective trial. Urology. 2012;79:443.Google Scholar
  46. 46.
    Soave A, Dahlem R, Pinnschmidt HO, et al. Substitution urethroplasty with closure versus nonclosure of the buccal mucosa graft harvest site: a randomized controlled trial with a detailed analysis of oral pain and morbidity. Eur Urol. 2018;73:910.PubMedGoogle Scholar
  47. 47.
    Barbagli G, Lazzeri M. Re: tissue-engineered autologous urethras for patients who need reconstruction: an observational study. Eur Urol. 2011;60:1303.PubMedGoogle Scholar
  48. 48.
    Barbagli G, Akbarov I, Heidenreich A, et al. Anterior urethroplasty using a new tissue engineered oral mucosa graft: surgical techniques and outcomes. J Urol. 2018;200:448.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Terlecki RP, Steele MC, Valadez C, et al. Urethral rest: role and rationale in preparation for anterior urethroplasty. Urology. 2011;77:1477.Google Scholar
  50. 50.
    Moncrief T, Gor R, Goldfarb RA, et al. Urethral rest with suprapubic cystostomy for obliterative or nearly obliterative urethral strictures: urethrographic changes and implications for management. J Urol. 2018;199:1289.Google Scholar
  51. 51.
    Angermeier KW, Rourke KF, Dubey D, et al. SIU/ICUD consultation on urethral strictures: evaluation and follow-up. Urology. 2014;83:S8.PubMedGoogle Scholar
  52. 52.
    Gupta N, Dubey D, Mandhani A, et al. Urethral stricture assessment: a prospective study evaluating urethral ultrasonography and conventional radiological studies. BJU Int. 2006;98:149.PubMedGoogle Scholar
  53. 53.
    Morey AF, McAninch JW. Sonographic staging of anterior urethral strictures. J Urol. 2000;163:1070.PubMedGoogle Scholar
  54. 54.
    Kuo TL, Venugopal S, Inman RD, et al. Surgical tips and tricks during urethroplasty for bulbar urethral strictures focusing on accurate localisation of the stricture: results from a tertiary centre. Eur Urol. 2015;67:764.PubMedGoogle Scholar
  55. 55.
    Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol. 2011;59:797.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Asopa HS, Garg M, Singhal GG, et al. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology. 2001;58:657.Google Scholar
  57. 57.
    Barbagli G, Palminteri E, Guazzoni G, et al. Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: are results affected by the surgical technique? J Urol. 2005;174:955.PubMedGoogle Scholar
  58. 58.
    Kulkarni S, Barbagli G, Sansalone S, et al. One-sided anterior urethroplasty: a new dorsal onlay graft technique. BJU Int. 2009;104:1150.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Aldaqadossi H, El Gamal S, El-Nadey M, et al. Dorsal onlay (Barbagli technique) versus dorsal inlay (Asopa technique) buccal mucosal graft urethroplasty for anterior urethral stricture: a prospective randomized study. Int J Urol. 2014;21:185.PubMedGoogle Scholar
  60. 60.
    Figler BD, Malaeb BS, Dy GW, et al. Impact of graft position on failure of single-stage bulbar urethroplasties with buccal mucosa graft. Urology. 2013;82:1166.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Hosseini J, Kaviani A, Hosseini M, et al. Dorsal versus ventral oral mucosal graft urethroplasty. Urol J. 2011;8:48.PubMedGoogle Scholar
  62. 62.
    Pathak HR, Jain TP, Bhujbal SA, et al. Does site of buccal mucosa graft for bulbar urethra stricture affect outcome? A comparative analysis of ventral, dorso-lateral and dorsal buccal mucosa graft augmentation urethroplasty. Turk J Urol. 2017;43:350.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Vasudeva P, Nanda B, Kumar A, et al. Dorsal versus ventral onlay buccal mucosal graft urethroplasty for long-segment bulbar urethral stricture: a prospective randomized study. Int J Urol. 2015;22:967.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Guralnick ML, Webster GD. The augmented anastomotic urethroplasty: indications and outcome in 29 patients. J Urol. 2001;165:1496.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Gelman J, Siegel JA. Ventral and dorsal buccal grafting for 1-stage repair of complex anterior urethral strictures. Urology. 2014;83:1418.Google Scholar
  66. 66.
    Palminteri E, Lumen N, Berdondini E, et al. Two-sided dorsal plus ventral oral graft bulbar urethroplasty: long-term results and predictive factors. Urology. 2015;85:942.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Palminteri E, Manzoni G, Berdondini E, et al. Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. Eur Urol. 2008;53:81.PubMedPubMedCentralGoogle Scholar
  68. 68.
    Morey AF, McAninch JW. When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology. 1996;48:194.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Barbagli G, Montorsi F, Guazzoni G, et al. Ventral oral mucosal onlay graft urethroplasty in nontraumatic bulbar urethral strictures: surgical technique and multivariable analysis of results in 214 patients. Eur Urol. 2013;64:440.PubMedPubMedCentralGoogle Scholar
  70. 70.
    Barbagli G, Selli C, Tosto A, et al. Dorsal free graft urethroplasty. J Urol. 1996;155:123.PubMedPubMedCentralGoogle Scholar
  71. 71.
    Gelman J, Sohn W. 1-stage repair of obliterative distal urethral strictures with buccal graft urethral plate reconstruction and simultaneous onlay penile skin flap. J Urol. 2011;186:935.PubMedPubMedCentralGoogle Scholar
  72. 72.
    Barbagli G, Guazzoni G, Lazzeri M. One-stage bulbar urethroplasty: retrospective analysis of the results in 375 patients. Eur Urol. 2008;53:828.PubMedGoogle Scholar
  73. 73.
    Pisapati VL, Paturi S, Bethu S, et al. Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. Eur Urol. 2009;56:201.PubMedPubMedCentralGoogle Scholar
  74. 74.
    Hoy NY, Kinnaird A, Rourke KF. Expanded use of a dorsal onlay augmented anastomotic urethroplasty with buccal mucosa for long segment bulbar urethral strictures: analysis of outcomes and complications. Urology. 2013;81:1357.PubMedPubMedCentralGoogle Scholar
  75. 75.
    El-Kassaby AW, El-Zayat TM, Azazy S, et al. One-stage repair of long bulbar urethral strictures using augmented Russell dorsal strip anastomosis: outcome of 234 cases. Eur Urol. 2008;53:420.PubMedPubMedCentralGoogle Scholar
  76. 76.
    Bryk DJ, Yamaguchi Y, Zhao LC. Tissue transfer techniques in reconstructive urology. Korean J Urol. 2015;56:478.PubMedPubMedCentralGoogle Scholar
  77. 77.
    Roehrborn CG, McConnell JD. Analysis of factors contributing to success or failure of 1-stage urethroplasty for urethral stricture disease. J Urol. 1994;151:869.Google Scholar
  78. 78.
    Jackson MJ, Sciberras J, Mangera A, et al. Defining a patient-reported outcome measure for urethral stricture surgery. Eur Urol. 2011;60:60.PubMedGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of UrologyNational Defense Medical CollegeTokorozawa-City, SaitamaJapan

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