Bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue.

Abstract

We describe a new surgical technique with the use of fibrin glue for bulbar urethra reconstruction using a dorsal buccal mucosal onlay graft.
Six patients with a mean age of 43 yr underwent bulbar urethroplasty with dorsal onlay buccal mucosal graft and fibrin glue. The urethra was mobilised from the corpora cavernosa and opened along its dorsal surface. The buccal mucosal graft was applied on the corpora cavernosa using 2 ml of fibrin glue. Two interrupted polyglactin 5-0 sutures were used to fix the apices of the graft to the underlying albuginea of the corpora cavernosa. The urethra was rotated back to cover the graft and an adjunctive fibrin glue was injected over the urethra.
The mean operative time was 100 min (range, 90-120 min). No intraoperative or postoperative complications were observed. Voiding cystourethrography was performed when the catheter was removed 2 wk after surgery. Urine culture, uroflowmetry, and urethrography were repeated after 6 and 12 mo and annually thereafter. Mean follow-up was 16 mo (range, 12-24 mo). No restrictures at the anastomotic sites were demonstrated in any of the patients 6 and 12 mo after surgery.
The use of fibrin glue represents a slight but significant step toward perfecting the surgical technique of bulbar urethral reconstruction.

Full text

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Surgery in Motion
Bulbar Urethroplasty with Dorsal Onlay Buccal Mucosal Graft
and Fibrin Glue
Guido Barbaglia,*, Stefano De Stefanib, Maria Chiara Sighinolfib,
Filippo Anninob, Salvatore Micalib, Giampaolo Bianchib
aCenter for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy
bDepartment of Urology, University of Modena-Reggio Emilia, Modena, Italy
1.Introduction
Numerous surgical techniques have been described
to repair bulbar urethral strictures according to
stricture length, including end-to-end anastomosis,
augmented roof strip anastomotic urethroplasty,
onlay repair using flap, or graft and multistaged
procedures [1].Short bulbar stricture, ranging from1
to 2 cm, is generally managed by primary end-to-
end anastomosis [2] and augmented anastomotic
european urology 50 (2006) 467–474
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journal homepage: www.europeanurology.com
Article info
Article history:
Accepted May 11, 2006
Published online ahead of
print on June 5, 2006
Keywords:
Buccal mucosa
Bulbar urethra
Graft
Fibrin glue
Urethral stricture
Urethroplasty
Abstract
Objectives: We describe a new surgical technique with the use of fibrin
glue for bulbar urethra reconstruction using a dorsal buccal mucosal
onlay graft.
Methods: Six patients with a mean age of 43 yr underwent bulbar ure-
throplasty with dorsal onlay buccal mucosal graft and fibrin glue. The
urethra was mobilised from the corpora cavernosa and opened along its
dorsal surface. The buccal mucosal graft was applied on the corpora
cavernosa using 2 ml of fibrin glue. Two interrupted polyglactin 5-0
sutureswereusedtofixtheapicesofthegrafttotheunderlyingalbuginea
of the corpora cavernosa. The urethra was rotated back to cover the graft
and an adjunctive fibrin glue was injected over the urethra.
Results: The mean operative time was 100 min (range, 90–120 min). No
intraoperative or postoperative complications were observed. Voiding
cystourethrography was performed when the catheter was removed 2
wk after surgery. Urine culture, uroflowmetry, and urethrography were
repeated after 6 and 12 mo and annually thereafter. Mean follow-up was
16 mo (range, 12–24 mo). No restrictures at the anastomotic sites were
demonstrated in any of the patients 6 and 12 mo after surgery.
Conclusions: The use of fibrin glue represents a slight but significant
step toward perfecting the surgical technique of bulbar urethral recon-
struction.
# 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Tel. +39 0575 403412; Fax: +39 0575 27056.
E-mail address: guido@rdn.it (G. Barbagli).
0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.doi:10.1016/j.eururo.2006.05.018

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urethroplasty is suggested for strictures 2–3 cm in
length [1,3–5]. Strictures longer than 3 cm are
generally managed using tissue (skin or buccal
mucosa) transfer procedures accomplished in a
variety of ways including dorsal or ventral onlay
graft urethroplasty [6–12]. Finally, in patients with
strictures longer than 6 cm involving both penile
and bulbar urethra or associated with local adverse
conditions, multistage urethroplasty or mesh graft
urethroplasty is mandatory [13,14].
Buccal mucosal onlay graft urethroplasty is one of
the most widely used methods for the repair of the
strictures in the bulbar urethra and provides excel-
lent results [6–12,15,16]. Stricture recurrences can,
however, occur despite using an adequate surgical
technique and substitution material may deteriorate
over time [15–17]. In our experience, stricture
recurrences after bulbar substitution onlay urethro-
plastyshowtwodifferentfeatures,namely,extensive
fibrous tissue involving the entire grafted area or a
short fibrous ring stricture at the distal or proximal
anastomotic sites where the apices of the graft are
sutured tothe apicesof the urethralplate[18–20].We
investigated the prevalence, location, and etiology of
these postoperative anastomotic ring strictures,
which can affect any type of substitution bulbar
urethroplasty [20]. Moreover, substitution urethro-
plasty using free graft requires a long catheterisation
time and postoperative urinary leakage at the
anastomotic site during the first postoperative radi-
ologic investigation may also require a more pro-
longed catheterisation time [6,9], causing a negative
psychologicalimpactonthepatient.Recently,theuse
of fibrin sealant was suggested to decrease immedi-
ateurinaryleakagefollowingprostatectomy[21]orto
reduce the catheterisation time following penile
urethroplasty [22].
We suggest here the use of fibrin glue in a new
technique of dorsal onlay buccal mucosal graft
urethroplasty to reduce the time of postoperative
catheterisation, the risk of postoperative urinary
leakage, and the incidence of postoperative anasto-
motic rings at the apices of the sutures between the
graft and the mucosal urethral plate.
2. Methods
Between January 2003 and December 2004, six patients with a
mean age of 42 yr (range, 26–64 yr) underwent bulbar
urethroplasty using buccal mucosal graft and fibrin glue.
The stricture etiology was instrumentation in four patients
and unknown in two. Five patients had undergone previous
urethrotomy or dilation. The average stricture length was
4.5 cm (range, 3–6 cm). Patients with lichen sclerosus, failed
hypospadias repair, previously failed urethroplasty, and a
stricture extending into the penile urethra (pan-urethral
disease) were not included in the study. In all patients, the
bulbarstricturesweremanagedusingadorsalurethralopening
describedby Barbagli etal. in 1996[6]. The buccalmucosalgraft
was applied over the albuginea of the corpora cavernosa using
fibrin glue and the urethra was rotated back to cover the graft.
2.1.Preoperative evaluation
Each patient’s clinical history and chart were reviewed to
evaluate the presence of previous perineal blunt trauma or
previousrepeatedurethrotomyorurethroplastyfailureandthe
genitalia were inspected to exclude the presence of lichen
sclerosus disease. Preoperative tests included urine culture,
residual urine measurement, retrograde and voiding cystour-
ethrography, sonourethrography, and urethroscopy. The etiol-
ogy of the stricture and its location and length were carefully
examined to better define the characteristics needed in the
buccal mucosal graft. Finally, patients who currently had an
infectious disease affecting the mouth (such as candida,
varicella virus, or herpes virus) or who had previous surgery
in the mandibular arch that prevented the mouth from being
opened wide, or who played a wind instrument were informed
that genital or extra genital skin would be used for the
urethroplasty. Patients were fully informed that bulbar ure-
throplasty is a safe procedure as far as sexual function is
concerned.
2.2. Surgical technique
2.2.1.
The patient is placed in a simple low lithotomy position. The
patient’s calves are carefully placed in Allen stirrups with
sequential inflatable compression sleeves and the lower
extremities are then suspended by the patient’s feet within
the boots of the stirrups. Proper positioning ensures that there
is no pressure on any aspect of the calf muscles and no inward
boot rotation to avoid peroneal nerve injury. The skin of the
suprapubic region, scrotum, and perineum is shaved and this
region is prepared and draped appropriately.
Preparation of the bulbar urethra
european urology 50 (2006) 467–474
468
Fig. 1 – The midline perineal incision is underlined.

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Methylene blue is injected into the urethra to better define
the urethral mucosa involved in the disease. A midline
perineal incision is made overlying the stricture site (Fig. 1).
The bulbocavernous muscles are separated in the midline
(Fig. 2) and, in patients with proximal urethral stricture, the
central tendon of the perineum is dissected. The urethra is
freed from the bulbocavernous muscles for its entire length
and the muscles are fixed to a retractor using four stitches
(Fig. 3). The bulbar urethra is dissected from the corpora
cavernosa (Fig. 4). The urethra is rotated 1808 and the distal
extent of the stenosis is identified by gently inserting a 16F
catheter with a soft round tip until it meets resistance (Fig. 5).
The dorsal urethral surface is incised in the midline until the
catheter tip and urethral lumen are exposed. The stricture is
then incised along its entire length by extending the
urethrotomy distally and proximally (Fig. 6). Once the entire
stricture has been incised, the length and width of the
remaining urethral plate is measured. Proximal and distal
calibration of the urethra with modified nasal speculum is
critical for identifying any residual narrowing. The buccal
mucosal graft is trimmed to an appropriate size according to
the length and width of the urethrotomy.
european urology 50 (2006) 467–474
469
Fig. 2 – The bulbocavernous muscles are separated on the
midline.
Fig. 3 – The bulbar urethra is completely freed from the
bulbocavernous muscles and the muscles are fixed to
retractor.
Fig. 4 – The urethra is dissected from the corpora
cavernosa.
Fig. 5 – The urethra is rotated of 1808 using a loop. The
catheter is inserted and the incision on the dorsal urethral
surface is underlined.

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2.2.2.
Recently, we fully described our current surgical technique for
harvesting buccal mucosal graft from the inner cheek,
including postoperative complications and patient discomfort
[23].
The patient is intubated through the nose, allowing the
mouth to be completely free. The patient is draped in two
separated parts and two surgical teams work simultaneously.
Each team has its own set of surgical instruments, including
suction and bipolar cautery. By using a mouth retractor that
has its own light, only one assistant is needed to harvest the
buccalmucosa.Theinnermucosalsurfaceoftherightcheekis
prepared and disinfected, and stay sutures are placed along
the external edge of cheek to keep the buccal mucosa
stretched. The Stensen duct, located at the level of the second
molar, is identified and the desired graft size is measured and
marked in an ovoid shape. Lidocaine HCl 1% with epinephrine
(1:100,000) is injected along the edges of the graft to enhance
hemostasis. The outlined graft is sharply dissected and
removed. The donor site is carefully examined for bleeding
and is closed with 4-0 polyglactin sutures. The graft is
stabilised on a silicone board using insulin needles. After
careful deflation with microsurgical instruments, the graft is
tailored according to site, length, and stricture characteristics.
An ice bag is applied to the cheek to reduce edema, pain and
haematoma.
Cheek harvesting technique
2.2.3.
fibrin glue
The bulbar urethra is moved to the right side and fibrin glue
(2 ml) is injected over the albuginea of the corpora cavernosa.
The buccal mucosal graft is spread fixed over the fibrin glue
bed (Fig. 7). The two apices of the graft are sutured to the
proximal and distal apices of the urethrotomy (Fig. 8). A Foley
16Fgroovedsiliconecatheterisinserted.Thebulbarurethrais
rotated to its original position over the graft (Fig. 9). Three
interrupted 4-0 polyglactin sutures for each side are used to
Sticking the graft to the albuginea of the corpora using
stabilise the urethral margins to the corpora cavernosa over
the graft (Fig. 10). At the end of the procedure the graft is
completely covered by the urethra and fibrin glue (2 ml) is
injected over the urethra to prevent urinary leakage. The
bulbocavernous muscles are sutured over the spongiosum
tissue (Fig. 11). Colles fascia, the perineal fat, and the skin are
closedwithinterruptedabsorbablesutures(Fig.12).Asuction
drain is left in place for 1 d. The catheter is left in place for 2
wk.
2.2.4.
The patient consumes a clear liquid diet and ice cream before
advancing to a soft, then regular diet. The patient ambulates
on the first postoperative day and is discharged from the
Postoperative care
european urology 50 (2006) 467–474
470
Fig. 6 – The stenosis is fully opened.
Fig. 7 – The buccal mucosal graft is fixed over the albuginea
of corpora cavernosa using fibrin glue.
Fig. 8 – The apices of graft are fixed to the albuginea and to
the apices of urethrotomy.

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hospital 3 d after surgery. All patients receive postoperative
broad-spectrum antibiotics and are maintained on oral
antibiotics until the catheter is removed. Two weeks after
surgery the bladder is filled with contrast medium, the Foley
catheter is removed, and voiding cystourethrography is
obtained.
2.2.5.
A possible early minor complication is urethrorrhagia due to
nocturnal erections. Possible later minor complications are
temporary numbness, dysesthesia to the perineum, and
scrotal swelling.
Postoperative complications
3.Results
Clinical outcome was considered a success or a
failure at the time that any postoperative procedure
was needed, including dilation. The mean operative
time was 100 min (range, 90–120 min). No intra-
operativeorpostoperative
observed. In all patients, postoperative voiding
cystourethrography was performed 2 wk after
surgery and no urinary leakage was present. Urine
culture, uroflowmetry, and urethrography were
repeated after 6 and 12 mo and annually thereafter.
Average follow-up was 16 mo (range, 12–24 mo).
No restrictures at the anastomotic sites were
demonstrated in any of the patients at 6 and 12
mo after surgery.
complications were
european urology 50 (2006) 467–474
471
Fig. 10 – The urethra is fixed to the corpora cavernosa.
Fig. 9 – The urethra is rotated back to its original position to
cover the graft.
Fig. 11 – The bulbocavernous muscles are closed over the
urethra.
Fig. 12 – Suction drain and Foley catheter are left in place.