A buccal mucosal graft subcoronal resurfacing technique to treat recurrent penile adhesions: the buccal belt.

OBJECTIVE: To outline our step-by-step surgical technique using a subcoronal buccal mucosal graft (BMG) resurfacing technique for the treatment of recurrent penile adhesions. METHODS: To perform the 'buccal belt' procedure a subcoronal circumferential segment of diseased skin was excised. An appropriately sized BMG was circumferentially secured subcoronally with a proximal and distal anastomosis to the edges of the wound. Quilting stitches were also placed to allow proper graft fixation. A petroleum jelly bolster was secured as a tie-over dressing. Patients were discharged with a Foley catheter and the bolster dressing in place. The bolster and Foley catheter were removed 7 days postoperatively. The patients were then seen for follow-up at 4- to 6-month intervals. A retrospective, international multi-institutional review was conducted to include all patients who underwent this procedure. Surgical complications, evidence of recurrence, and patient-reported outcome measures including visual analogue scale (VAS) and global response assessment (GRA) questionnaires were reviewed. RESULTS: Thirty-one men underwent the procedure across six institutions between March 2014 and September 2020. The mean (range) surgical time was 59 (25-95) min. At the mean (range) follow-up of 27 (4-79) months all patients reported resolution of presenting symptoms and no recurrence of adhesions. The mean VAS score was 8.9 and 9.0 for aesthetics and functional outcomes, respectively. On GRA, overall improvement was reported by all patients (61%, +3; 25%, +2; 14%, +1). CONCLUSION: There are limited options for the treatment of recurrent penile adhesions. A subcoronal BMG resurfacing is feasible, with no recurrence and overall high satisfaction seen in an initial patient cohort.

The buccal belt: a buccal mucosal graft sub-coronal resurfacing for recurrent penile adhesions in patients with lichen sclerosus.

BACKGROUND: Penile adhesions may cause pain, bleeding, disfigurement and distress. In the setting of lichen sclerosus (LS), they often recur but current treatment options are limited. We present a novel surgical technique for treatment of recurrent penile adhesions using sub-coronal buccal mucosal graft (BMG) resurfacing. METHODS: A retrospective, international multi-institutional study was conducted to include patients with refractory penile adhesions who were treated with this technique. Patients with > 12-month follow-up were included in analysis. The procedure involved circumferential excision of the diseased skin and replacement with a BMG. The primary outcomes were recurrence and surgical complications. Secondary outcomes were patient-reported outcome measures (PROMs) including Sexual Health Inventory for Men (SHIM) questionnaire and Global Response Assessment (GRA) questionnaire measuring functional and esthetic outcomes. RESULTS: Twenty-five men underwent the procedure across six institutions between 3/2014 and 11/2019. Twenty-one men met inclusion criteria. Mean operative time and hospital stay for sub-coronal resurfacing were 40 min (25-50) and 0.76 days (1-2), respectively. At the mean follow-up of 18 months (12-61), no patients developed recurrence. All patients who presented with pain and postcoital bleeding saw improvement on follow-up (18/18). There was a significant improvement in SHIM scores after the operation (14.4 pre-op, 17.0 post-op; p = 0.003). Overall improvement of symptoms was reported by all patients: 57% GRA + 3; 29% GRA + 2; 14% GRA + 1. Baseline penile sensation was preserved in 17/21 (81%) patients. CONCLUSIONS: Recurrent penile adhesions in the setting of LS are notoriously difficult to treat. A sub-coronal BMG resurfacing is feasible. This initial patient cohort demonstrated no recurrence and overall high satisfaction.

Dorsal buccal graft urethroplasty in female urethral stricture disease: a multi-center experience.

BACKGROUND: Female urethral stricture disease is under-recognized and is often treated with dilation despite poor definitive outcomes. Our objective was to describe a multi-institutional experience treating female urethral stricture disease with female dorsal onlay buccal mucosa graft (FD-BMG) urethroplasty outcomes. METHODS: We retrospectively identified 39 consecutive FD-BMG urethroplasty operations performed by 6 reconstructive surgeons from 12/2007 to 1/2016. Surgical technique included dorsally-placed buccal mucosal grafts in all cases. Stricture recurrence was defined by cystoscopy. RESULTS: Mean age was 50 (range, 29-81) years. Stricture etiology was unknown (49%), iatrogenic (36%), or trauma/straddle injury (15%). A majority of women (87%) women had undergone a prior stricture-related urethral procedure(s) before the surgeons' index urethroplasty. Mean stricture length was 2.1 cm and mean caliber was 11 Fr. Mean postoperative follow-up was 33 (range, 7-106) months. Postoperative complications within 30 days were seen in 7 individuals (18%) and were all Clavien-Dindo grade II. Stricture recurrence was seen in 9 (23%) patients, with mean time to recurrence 14 months. No patients experienced de novo incontinence. CONCLUSIONS: FD-BMG urethroplasty is a safe and effective management option for female urethral strictures. Referral to a reconstructive center is encouraged to avoid repeated unnecessary endoscopic procedures that have poor definitive success.

Urethroplasty After Urethral Urolume Stent: An International Multicenter Experience.

OBJECTIVE: To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume urethral stent. MATERIAL AND METHODS: This is a retrospective international multicenter study on patients treated with urethral reconstruction after Urolume stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline, and posturethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure. RESULTS: Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14 (22.2%), dorsal onlay buccal mucosa graft (BMG) in 9 (14.3%), ventral onlay BMG in 6 (9.5%), dorsolateral onlay BMG in 9 (14.3%), ventral onlay plus dorsal inlay BMG in 3 (4.8%), augmented anastomosis in 5 (7.9%), pedicled flap urethroplasty in 6 (9.5%), 2-stage procedure in 4 (6.4%), and perineal urethrostomy in 7(11.1%). Success rate was 81% at a mean 59.7 ± 63.4 months. Dilatation or internal urethrotomy was performed in 10 (15.9%) and redo-urethroplasty in 5 (7.9%). Total International Prostate Symptom Score, quality of life, urine maximum flow, and postvoid residual significantly improved (P <.0001). Complications occurred in 8 (12.7%), all Clavien-Dindo ≤2. Disease-free survival rate after reconstruction was 88.1%, 79.5%, and 76.7% at 1, 3, and 5 years, respectively. Explant of individual strands followed by onlay BMG is the most common approach and was significantly advantageous over the other techniques (P = .018). CONCLUSION: Urethroplasty in patients with Urolume urethral stents is a viable option of reconstruction with a high success rate and very acceptable complication rate. Numerous techniques are viable; however, urethral preservation, tine-by-tine stent extraction, and use of BMG augmentation produced significantly better outcomes.

Augmented perineal urethrostomy using a dorsal buccal mucosal graft, bi-institutional study.

PURPOSE: To present our technique and outcomes for perineal urethrostomy augmented with a dorsal onlay buccal mucosa graft (BMG). Results from initial series and collaboration from an international center are included. METHODS: A retrospective chart review of all adult patients who underwent urethral reconstruction with perineal urethrostomy utilizing a buccal mucosal graft between January 1, 2002 and January 1, 2013 was performed. All surgeries were performed by three surgeons using the same technique (GHJ, KAM, and RV). Success was defined as no need for additional treatment following definitive surgery. RESULTS: A total of 44 patients met inclusion criteria. Mean patient age was 60 (range 44-81) years. All strictures were pananterior. Etiologies included unknown in 16 (36%), failed hypospadias repair in six (14%), lichen sclerosus in ten (23%), iatrogenic in seven (16%), Fournier's in three (7%), urethral cancer in one (2%) and penile cancer in one (2%). Mean follow-up was 45 (range 6-136) months. Overall success was 80%. Nine patients recurred, of which four had a successful revision, two are awaiting potential revision, and three are being managed with periodic dilations. CONCLUSIONS: BMG perineal urethrostomy is a valid alternative for complex urethral strictures due to lichen sclerosus, previous failed reconstructions or hypospadias cripples. Midterm results are encouraging for this novel technique.

[Buccal mucosa graft augmented anastomotic urethroplasty for the treatment of bulbar urethral strictures]. / GAL EN EL TRATAMIENTO DE LA ESTRECHEZ DE URETRA BULBAR.

OBJECTIVE: To report our outcomes with the use of buccal mucosal graft anastomotic urethroplasty to reconstruct complex anterior urethral strictures. METHODS: Between October 2007 and January 2011 we conducted a retrospective review of a series of 65 patients from 2 different centers. We analyzed demographic data, surgical outcomes and complications. RESULTS: Patient mean age was 50.09 years (range: 25 to 75), mean stricture length was 3.95 cm (range: 3 to 7 cm) and mean follow-up 33.13 months (range: 12.7 to 52.77). Eighty percent of patients had prior treatments, mainly direct visual internal urethrotomy (DVIU) and urethral dilatation. Most frequent etiologies were iatrogenic in 46.15% of patients and idiopathic in 35.38% of patients. Success rate was achieved in 96.92% of patients; only 2 patients presented recurrence and were treated successfully with one DVIU. Clavien Dindo I-II complications were found in 59% of patients. No patient had chronic sequels. CONCLUSION: Augmented anastomotic urethroplasty using dorsal onlay buccal mucosa graft enables correction, in one time, of long segment urethral strictures with severe spongiofibrosis and/or obliterated lumen. Our outcomes are comparable with those of previously reported in international series.

Anastomosis ampliada con injerto de mucosa yugal en el tratamiento de la estrechez de uretra bulbar / Buccal mucosa graft augmented anastomotic urethroplasty for the treatment of bulbar urethral strictures

OBJETIVO: Reportar nuestros resultados con la utilización de la anastomosis ampliada con injerto de mucosa yugal para el manejo de la estrechez compleja de la uretra bulbar. MÉTODOS: Análisis retrospectivo de 65 pacientes operados en 2 Centros Hospitalarios independientes de cirugía reconstructiva, entre octubre de 2007 y enero de 2011. Se analizaron datos demográficos, resultados y complicaciones. RESULTADOS: La edad promedio de los pacientes fue de 50,09 años (rango: 25 a 75), siendo la longitud media de la estrechez de 3,95 cm (rango: 3 a 7) y un seguimiento promedio de 33,13 meses (rango: 12,7 a 52,77). El 80% de los pacientes había sido tratado previamente con múltiples uretrotomías internas y dilataciones. Las etiologías más frecuentes fueron instrumental (46,15%) e idiopática (35,38%). La tasa de éxito fue del 96,92%, recidivando en 2 pacientes, que fueron exitosamente tratados con uretrotomía interna. Las complicaciones fueron menores, Clavien Dindo I-II, ocurriendo en el 39,92% de los pacientes, y ninguna de ellas dejó secuelas incapacitantes a largo plazo. CONCLUSIÓN: La anastomosis ampliada permite corregir en un tiempo extensos procesos cicatrizales de la uretra y con gran compromiso de la luz uretral. Los resultados obtenidos en nuestra serie se comparan con aquellos de las series internacionales ya reportados

OBJECTIVE: To report our outcomes with the use of buccal mucosal graft anastomotic urethroplasty to reconstruct complex anterior urethral strictures. METHODS: Between October 2007 and January 2011 we conducted a retrospective review of a series of 65 patients from 2 different centers. We analyzed demographic data, surgical outcomes and complications. RESULTS: Patient mean age was 50.09 years (range: 25 to 75), mean stricture length was 3.95 cm (range: 3 to 7 cm) and mean follow-up 33.13 months (range: 12.7 to 52.77). Eighty percent of patients had prior treatments, mainly direct visual internal urethrotomy (DVIU) and urethral dilatation. Most frequent etiologies were iatrogenic in 46.15% of patients and idiopathic in 35.38% of patients. Success rate was achieved in 96.92% of patients; only 2 patients presented recurrence and were treated successfully with one DVIU. Clavien Dindo I-II complications were found in 59% of patients. No patient had chronic sequels. CONCLUSION: Augmented anastomotic urethroplasty using dorsal onlay buccal mucosa graft enables correction, in one time, of long segment urethral strictures with severe spongiofibrosis and/or obliterated lumen. Our outcomes are comparable with those of previously reported in international series

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.

OBJECTIVE: To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra. MATERIALS AND METHODS: From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007). RESULTS: Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty. CONCLUSION: Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

[Penile fracture with associated urethra lesion: case report and bibliographic review]. / Fractura de pene con lesión asociada de uretra: presentación de un caso y revision de la literatura.

OBJECTIVE: Penile fracture is a rare lesion that occurs almost exclusively during erection. This lesion may be associated with rupture of the urethra in 20-30% of the cases. We describe a case that has been treated at our institution and review the literature. METHODS: A-42-year-old patient suffered fracture of penis, with urethral section, during sexual intercourse. The patient underwent surgical exploration, the lesions of the corporal bodies and urethra were identified. Both lesions were repaired. RESULTS: patient's recovery was satisfactory without complications or esthetical or functional sequelae. CONCLUSIONS: Penile fracture with urethral section is an exceptional disease, the most frequent cause of which in occident is violent sexual activity. For diagnosis it is necessary in most cases a correct anamnesis and physical examination. Early surgical approach and closure of the albuginea's lesion and repair of the urethral lesion is the best way of treatment.

Fractura de pene con lesión asociada de uretra: presentación de un caso y revisión de la literatura / Penile fracture with associated urethra lesion: Case report and bibliographic review

Objetivo: La fractura de pene es una lesión que responde habitualmente a un traumatismo cerrado que ocurre con el pene en erección. Cerca del 20-30% de los casos en occidente, se asocian a lesión del cuerpo esponjoso. Presentamos el caso de un paciente atendido en nuestro servicio y realizamos una revisión de la literatura. Métodos: Se trata de un paciente de 42 años de edad, que luego de una relación sexual violenta, presentó una fractura de pene con lesión asociada de uretra. Se lo intervino quirúrgicamente, se constató la lesión de ambos cuerpos cavernosos y la sección completa de de la uretra. Ambas lesiones fueron reparadas en el mismo acto quirúrgico. Resultados: El paciente evolucionó satisfactoriamente sin complicaciones y sin secuelas estéticas ni funcionales. Conclusiones: La fractura de pene con lesión asociada de uretra es una patología excepcional, cuya etiología más frecuente en occidente se debe a una relación sexual violenta. Una correcta anamnesis y un examen físico correcto son suficientes en la mayoría de los casos para hacer diagnóstico. El abordaje quirúrgico temprano y el cierre de la albuginea junto a la reparación de la uretra, permite alcanzar los mejores resultados (AU)

Objective: Penile fracture is a rare lesion that occurs almost exclusively during erection. This lesion may be associated with rupture of the urethra in 20-30% of the cases. We describe a case that has been treated at our institution and review the literature. Methods: A 42 years old patient suffered fracture of penis, with urethral section, during sexual intercourse. The patient underwent surgical exploration, the lesions of the corporal bodies and urethra were identified. Both lesions were repaired. Results: patient's recovery was satisfactory without complications or esthetical or functional sequelae. Conclusions: Penile fracture with urethral section is an exceptional disease, the most frequent cause of which in occident is violent sexual activity. For diagnosis it is necessary in most cases a correct anamnesis and physical examination. Early surgical approach and closure of the albuginea's lesion and repair of the urethral lesion is the best way of treatment (AU)