ABSTRACT
OBJECTIVE@#To describe the technique and report the first transurethral buccal mucosal graft ventral inlay (Nikolavsky Technique) urethroplasty done in the Philippines, in a patient who had a fossa navicularis stricture extending to the distal penile urethra.@*METHODS@#Reported here is a case of a twenty-seven-year-old male who had a 40% distal urethral mucosal tear, as seen on initial cystoscopy, following traumatic catherization. The urethral tear was initially managed with a foley catheter maintained for a month. However, the patient eventually developed a 4 cm stricture extending from the fossa navicularis to the distal penile urethra. A ventral buccal mucosal graft was placed on the denuded urethral plate as an inlay patch via the transurethral route. No skin incisions nor penile degloving was done@*RESULTS@#Total operative time was four hours, including graft harvest time, with approximately 400 ml blood loss. The patient was sent home on the 3rd postoperative day. The urethral catheter was removed after 14 days. Post-operative follow-up was performed at 0-, 3- 6- and 12-months. A repeat voiding cystourethrogram was performed at 4 weeks showing no narrowing at the prior stricture site. On 12 months follow-up, uroflowmetry showed a Q-max of 20ml/sec with minimal residual urine. LUTS symptom scoring was at 7 and IIEF-5 score of 25@*CONCLUSION@#Repair of distal urethral strictures can be done using transurethral ventral buccal mucosa graft inlay urethroplasty. It can be challenging for longer strictures (>4 cm) but easily reproducible for shorter ones. The technique demonstrated good results on medium term follow-up. To the authors’ knowledge, this is the first reported case that utilized this technique in the Philippines.
ABSTRACT
INTRODUCTION@#Urethroplasty is the gold standard treatment for urethral stricture disease, regardless of the reconstructive technique utilized, because of its high success rate as compared with endoscopic urethrotomy or simple dilation. Among the different urethroplasty techniques, the Kulkarni Procedure has gained wide acceptance worldwide for strictures of varying etiologies. This is the first ever local experience study to review this one-sided dissection technique aimed at preserving the lateral blood and nervous supply to the urethra thereby increasing the chances of graft survival.@*METHODS@#A retrospective review from October 2017 – October 2021 was done. Twenty male patients were included. Their ages ranged from 24 to 75 years old (mean age 43). The patient underwent one-sided urethral dissection followed by dorsal onlay mucosal graft urethroplasty. All the surgeries were performed by a single surgeon. On follow up, outcomes were measured using a variety of tools. Incidence of postoperative complications and stricture recurrence were likewise noted.@*RESULTS@#In this study, 20 patients underwent one-sided dorsal onlay BMG (buccal mucosal graft) urethroplasty (Kulkarni technique), from October 2017 to October 2021.The outcome was deemed successful if the patient no longer needed additional procedures after the initial surgery. Of the 20 patients, 18 had successful outcomes. The other 2 patients had to undergo a redo urethroplasty.@*CONCLUSION@#This technique was shown to have an overall success rate of 92% in 24 patients, with a follow-up period of 12-55 months based on Kulkarni’s initial report in 2009. The results of the present study are similar wherein the overall success rate was 90% in 20 patients, but on a shorter follow up period. Despite the small sample size and short follow-up period, the results of the initial experience are very promising. As urologists gain more experience, they can achieve higher success rates in the future.
ABSTRACT
@#Urethral strictures in females are very uncommon. In selected populations of women who underwent urodynamic studies for obstructive symptoms, female urethral strictures represent 4-13% of the causes of bladder outlet obstruction. Literature is limited regarding surgical treatment for near-obliterative urethral strictures in female patients. In this paper, the authors aimed to report a novel technique of double-faced inlay buccal mucosal graft (BMG) urethroplasty, first described by Joshi in 2020. This is a case of a 35-year-old female with progressively worsening lower urinary tract symptoms, several months after undergoing cesarean section despite multiple internal urethrotomies. Grafts were placed both the anterior and posterior urethral walls with noted good urine flow with mild lower urinary tract symptoms on follow-up after 6 months. The combined dorsal and ventral inlay BMG urethroplasty is a feasible technique with good results for female patients with urethral strictures. To the authors’ knowledge, this is the first-ever reported case, for this novel technique, in the Philippines.
ABSTRACT
Background: The objective of the study was to evaluate long term efficacy and outcome of use of buccal mucosal graft (BMG) for urethral reconstruction in varied urologic conditions in children.Methods: We retrospectively reviewed the medical records of 41 patients from 2009 till 2019 in our institution in which BMG was used for urethral reconstruction. Clinical findings along with surgical techniques used were noted for these patients. Postoperative outcome and complications were evaluated.Results: Mean age was 6.8 years and mean follow up was for 4 years. Out of 41 patients, BMG for substitution urethroplasty was used in 25 cases of hypospadias, 4 cases of urethral stricture, 6 cases of 46 XY disorders of sexual disorders, 4 cases of Y-duplication of urethra, and 2 cases of redo-epispadias repair. 11 patients underwent one stage repairs with a success rate of 63% and 30 patients underwent two stage repair with a success rate of 66%. Analysis and comparison of the outcome in relation to the type of repair, meatal position and number of surgical procedures prior to BMG urethroplasty was statistically insignificant.Conclusions: Buccal mucosa is an ideal graft substitute for urethroplasty. Two stage reconstructions has a slightly higher success rate than one stage reconstruction but the choice of the technique must be based on patients characteristics and on surgeons preference.
ABSTRACT
Background: Urethral stricture is a relatively common disease. The choice of surgery is based on the stricture location, length of the stricture and etiology. Buccal mucosal graft (BMG) urethroplasty with Asopa and Kulkarni techniques, revolutionized the approach to anterior urethral stricture repair. Objective of the study was to compare both the dorsal onlay BMG urethroplasty technique of Kulkarni and the dorsal inlay BMG urethroplasty technique of Asopa for the management of long anterior urethral stricture. Methods: From January 2015 to October 2019, a total of 90 patients with long anterior urethral strictures were randomized into two groups. Group A (42 patients) managed by Kulkarni technique. Group B (48 patients) managed by Asopa technique. BMG urethroplasty was considered successful if no further procedure required postoperatively with maximum flow rate >15 ml/s during the follow-up period.Results: The success rate in group A and B were 80.9% and 87.5%, respectively. The mean operative time was significantly longer in group A (175±22.6 min) than in group B (102±18.14 min, p-value <0.001). The average blood loss was significantly higher in group A (154±15.65 ml) than in group B (112.76±12.62 ml, p-value <0.012).Conclusions: The dorsal onlay technique of Kulkarni and the dorsal inlay technique of Asopa buccal mucosal graft urethroplasty are reliable and satisfactory procedures with good success rates and minimum complications.
ABSTRACT
Background: A urethral stricture is a scar of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen. As the constriction progresses, obstruction develops and leads to symptoms either directly related to the obstruction or as a secondary consequence.Methods: All the cases of stricture urethra presented to our institute between June 2017 to June 2019 (n=60) in whom treatment was required were studied in a prospective manner. All cases of obstructive voiding symptoms are evaluated by conducting uroflowmetry studies (ESPON, gravimetric type). Obstructive voiding symptoms are evaluated by using the American Urological Association questionnaire.Results: The data collected was divided into 3 groups: infective causes of stricture (n=22), traumatic causes of stricture (n=14) and idiopathic causes of stricture (n=24). The mean age of presentation was 34.4 years (range of 20 to 50 years). 18 (30.00%) patients had stricture in the bulbo-urethra, 12 (20.00%) at the external meatus, 4 patients had stricture at the bulbo-membranous region. Procedures undertaken during the study were visual internal urethrotomy in 20, anastomotic urethroplasty in 17 patients and Augmented urethroplasty in 23 patients. In our series of 60 patients, 48 patients had a Qmax of >15 ml/sec. Average success rate was 80.1%, 12 patients had a Qmax of <15 ml/sec.Conclusions: It is unwise to make sweeping recommendations for best practice for reconstructive urethral surgery based on the literature because each patient clearly requires an individualized approach based on individual circumstances. Buccal mucosa is the most widely used graft has excellent results in all types of urethroplasty.
ABSTRACT
Urethral stricture is a common disease with changing etiology and changing practices in management. Management options were grossly determined by cause, site, length of stricture and also by other factors like prior attempts of repair and local genital skin condition. Treatment options vary from dilatation, optical urethrotomy to various types of urethroplasty. Substitution urtethroplasty is done using various types of graft materials like skin, buccal mucosa, bladder mucosa or colonic mucosa. Over the past 10-15 years buccal mucosa grafts have been increasingly used in the urethral reconstruction. Barbagli technique (Dorsal onlay technique) has the advantages of no sacculation which is seen with ventral onlay grafts, good neovascularity and less shrinkage (10%) rate. We have presented the results and complications of doral onlay buccal mucosa graft urethroplasty (Barbagli technique) in 20 cases performed over a period of 30 months in our institution. Our study showed a success rate of 80% at the end of 2yrs follow up, comparable with other studies, with a restructure rate of 20%. None of our patients developed urethrocutaneous fistula and urethral diverticulum.
ABSTRACT
Introduction: Urethral stricture is a common condition with varying etiology and management, determined by cause, site and length of stricture. Materials and methods: We presented here a randomized prospective trial comparing dorsal onlay buccal mucosa graft and penile skin flap urethroplasty at our institute over 3 years period. Results: Total 22 patients underwent substitution urethroplasty during this period. The mean age and follow up was 31.31 years and 9 months respectively. The most common cause of stricture urethra was post inflammatory (40.90%) followed by traumatic (36.36%) and balanitis xerotica obliterence (22.72%). Majority had combined penobulbar stricture (45.45%), followed by penile (31.81%) and bulbar (22.7%). The average size of the urethral stricture was 6.81 cm. The most common symptom of presentation of stricture urethra was thin stream (100%) followed by dysuria (80%), frequency (71.42%) and dribbling (30%). Most of the patients underwent surgical procedure prior to presentation; urethral dilatation done in 13 (59.05%) patients followed by visual internal urethrotomy 7 (31.81%) patients and suprapubic cystostomy in 4 (18.18%) patients. Of 22 patients, 10 (45.45%) underwent local flap and 12 (54.54%) patients buccal mucosal graft. Out of 10 local flap technique, 8 (36.36%) patients underwent ventral longitudinal flap and 2 (9.09%) underwent Quartey flap. Out of 12 buccal mucosal graft technique, 5 (22.72%) patients underwent ventral onlay graft, 5 (22.72%) dorsal onlay and 2 (9.09%) tube circumferential graft. Total success rate was 72.72%. Success rate was higher with buccal mucosal graft (83.33%) compared to local flap technique (60%). Among local G. Mallikarjuna, N. Ramamurthy, G. Ravichander, Ravi Jahagirdar, Jagadeeshwar. Substitution urethroplasty: Buccal mucosal graft Vs local flaps - A prospective randomized study. IAIM, 2016; 3(10): 162-173. Page 163 flap technique, ventral longitudinal flap (62.5%) had better results than quartey flap (50%). Among buccal mucosal graft dorsal onlay graft had best (100%) results followed by ventral onlay (80%) and then tube circumferencial graft (50%). Patients with smaller stricture length (2.5-7.5 cm) had better (75%) results. Patients with combined penobulbar (90%) and BXO as etiology (80%) also had better results. Conclusion: The success rate of buccal mucosal free graft substitution urethroplasty is better than local penile skin flaps in patients with anterior urethral strictures.
ABSTRACT
Background: The use of Buccal Mucosa Graft (BMG) urethroplasty represents the most widespread method of urethral stricture repair. We present our long-term experience with buccal mucosal grafts, placed either ventrally or dorsally with their short and long term complications. Methods: We repaired 43 bulbar urethral strictures with BMG from 2008 to 2011. Mean patient age was 31 years. The graft was harvested from the cheek under local anaesthesia. The graft was placed on the ventral or dorsal bulbar urethral surface in 18 and 25 cases, respectively. A recurrence even after single attempt of Direct Visual Internal Urethrotomy (DVIU) will be deemed as treatment failure. Data were analyzed using the‘t’ test and Fischer test. Results: Mean stricture length was 5.25 cm (range 1.5 to 9 cm) with mean follow up of 58 months (range 10 to 84 months). Only five patients were found to develop stricture at anastomotic site. Three of them voided normally after single attempt of DVIU. Other two patients (4.65 %) required further open surgery or repeat DVIU during follow up and were considered as failure. Five patients develop wound infection and one presented with urethrocutaneous fistula with no long term donor site complication. Conclusion: With long-term follow-up our series confirms the durability of BMG for the treatment of urethral strictures of more than one centimetre (cm) length with fewer side effects and we conclude that the site of placement of the graft did not affect the outcome.
ABSTRACT
PURPOSE: Many fingertip injuries are associated with nail injury and it is hard to repair to original shape due to its unique characteristic. Mucosal graft is used for a defect of the nail bed injury. Hereby, we introduce a DAP flap and buccal mucosal graft, with which we could reduce the defect size of the injured fingertip and donor site morbidity at the same time, without any need for harvesting additional skin from other part of hand. Also, mucosal graft makes good cosmetic and functional outcome of nail. METHODS: This method was performed in a 56-year-old man with fingertip injury on dorsal side of left thumb due to electrical saw. First, DAP flap was performed on the injured finger to reduce the size of the defect of fingertip and cover the bone exposure. Second, nail bed part of the DAP flap was de-epithelized and buccal mucosal graft was done from left side of intraoral cavity wall. RESULTS: Flap and graft survived without any necrosis but some nail bed could not be covered with flap due to insufficient flap size. All wounds healed well and did not present any severe adversary symptoms. CONCLUSION: DAP flap with mucosal graft is an effective method that we can easily apply in reconstruction of fingertip injury. We suggest that the combination of the two procedures makes good functional and cosmetic outcome compared to the usual manner, especially in cases of nail bed injury without distal phalanx bone defect.