Article

Penile and bulbar urethroplasty using dorsal onlay techniques

Authors:
  • Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy
Article

Penile and bulbar urethroplasty using dorsal onlay techniques

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Abstract

The armamentarium of the reconstructive urethral surgeon is continuously evolving and requires the surgeon to be familiar with new concepts and concerns. The great elasticity and handiness of the buccal mucosa may increase the number of new surgical techniques that arrange the graft in original ways. The dorsal approach to the urethral lumen allows a variety of surgical options that vary according to the stricture site and characteristics or to the surgeon's preference. Long-term follow-up will be necessary to establish whether buccal mucosa is superior to penile skin as a urethral substitute and, in the future, it is possible that other materials will be available. The dorsal onlay techniques are simple, reliable, and effective over the long term; reproducible in the hands of any surgeon; and do not require extensive training in reconstructive procedures using tissue transfer techniques.

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... Introduction Management of intractable anterior urethral strictures poses a continuing urological challenge. Buccal mucosal graft (BMG) urethroplasty has been the gold standard in the past decade for substitution urethroplasty, and the medium-term results have been good [1][2][3]. Traditionally, grafts have been placed on the ventral aspect of the urethra, because it allows easier access and better visualisation of the stricture [4], and ventrally placed grafts are likely to be associated with a higher rate of graft failure and diverticulae formation [5]. Barbagli et al [6] introduced dorsally placed grafts and postulated that dorsal placement is advantageous because the underlying corpora gives better mechanical support for the graft as well as blood supply. ...
... Moreover, the stricture site is directly seen, and the BMG can be tailored to the dorsal urethrotomy defect; in the dorsal urethrotomy approach, visualisation is rendered difficult by the rotation necessary for urethral incision dorsally. This technique may also be more suitable when the urethra is adherent to underlying corpora cavernosa as a consequence of repeated OUs and in obese patients where a dorsal approach may be particularly difficult [3]. The bleeding from the edges of the spongious urethra from the ventral urethrotomy site is more than in the dorsal urethrotomy technique but can usually be controlled effectively with diathermy or sutures. ...
Article
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Buccal mucosal graft (BMG) substitution urethroplasty has become popular in the management of intractable anterior urethral strictures with good results. Excellent long-term results have been reported by both dorsal and ventral onlay techniques. Asopa reported a successful technique for dorsal placement of BMG in long anterior urethral strictures through a ventral sagittal approach. To evaluate prospectively the results and advantages of dorsal BMG urethroplasty for recurrent anterior urethral strictures by a ventral sagittal urethrotomy approach (Asopa technique). From December 2002 to December 2007, a total of 58 men underwent dorsal BMG urethroplasty by a ventral sagittal urethrotomy approach for recurrent urethral strictures. Forty-five of these patients with a follow-up period of 12-60 mo were prospectively evaluated, and the results were analysed. The urethra was split twice at the site of the stricture both ventrally and dorsally without mobilising it from its bed, and the buccal mucosal graft was secured in the dorsal urethral defect. The urethra was then retubularised in one stage. The overall results were good (87%), with a mean follow-up period of 42 mo. Seven patients developed minor wound infection, and five patients developed fistulae. There were six recurrences (6:45, 13%) during the follow-up period of 12-60 mo. Two patients with a panurethral stricture and four with bulbar or penobulbar strictures developed recurrences and were managed by optical urethrotomy and self-dilatation. The medium-term results were as good as those reported with the dorsal urethrotomy approach. Long-term results from this and other series are awaited. More randomised trials and meta-analyses are needed to establish this technique as a procedure of choice in future. The ventral sagittal urethrotomy approach is easier to perform than the dorsal urethrotomy approach, has good results, and is especially useful in long anterior urethral strictures.
... 1,2 Traditionally, grafts have been placed on the ventral aspect of the urethra, because it allows easier access and better visualisation of the stricture, and ventrally placed grafts are likely to be associated with a higher rate of graft failure and diverticulae formation. 3,4 Barbagli et al introduced dorsally placed grafts and postulated that dorsal placement is advantageous because the underlying corpora gives better mechanical support for the graft as well as blood supply. 5 Asopa et al. described a ventral sagittal urethrotomy approach for dorsal free-graft urethroplasty and claimed that the procedure is easier to perform and better because the urethra is not mobilised. ...
... По мнению G. Barbagli [17][18][19][20][21][22][23][24], основным критерием при выборе хирургической тактики для лечения стриктур пенильной уретры является их этиология. Учитывая это, G. Barbagli и E. Palminteri предложили классификацию стриктур уретры в зависимости от этиологии заболевания, а также привели клиническую классификацию дефектов уретры различного генеза (табл. ...
Article
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The literary review is devoted to the very important medical and social problem – treatment of urethral strictures. The message is a historical excursion into the problem. Authors describe the development of scientific ideas about urethral stricture as a separate disease of the urinary canal: approaches to the definition of this pathology, the advantages and disadvantages of its various classifications, the role of various factors in the pathogenesis and their influence on the treatment effectiveness.
... Asopa's technique might also be more suitable when the urethra is adherent to underlying corpora cavernosa as a consequence of repeated optical urethrotomy and in obese patients where a dorsal approach could be particularly difficult. 22 In the present study, the average blood loss in the first group was significantly more than in the second group (228 ± 5.32 vs 105 ± 12.05, P-value <0.0001), which could be attributed to urethral dissection and rotation in Barbagli's technique. However in Asopa's technique, the bleeding from the edges of the spongious urethra at the ventral urethrotomy site is more than in the dorsal onlay technique, but can usually be controlled effectively with diathermy or sutures. ...
Article
To compare both the dorsal onlay technique of Barbagli and the dorsal inlay technique of Asopa for the management of long anterior urethral stricture. From January 2010 to May 2012, a total of 47 patients with long anterior urethral strictures were randomized into two groups. The first group included 25 patients who were managed by dorsal onlay buccal mucosal graft urethroplasty. The second group included 22 patients who were managed by dorsal inlay buccal mucosal graft urethroplasty. Different clinical parameters, postoperative complications and success rates were compared between both groups. The overall success rate in the dorsal onlay group was 88%, whereas in the dorsal inlay group the success rate was 86.4% during the follow-up period. The mean operative time was significantly longer in the dorsal onlay urethroplasty group (205 ± 19.63 min) than in the dorsal inlay urethroplasty group (128 ± 4.9 min, P-value <0.0001). The average blood loss was significantly higher in the dorsal onlay urethroplasty group (228 ± 5.32 mL) than in the dorsal inlay urethroplasty group (105 ± 12.05 mL, P-value <0.0001). The dorsal onlay technique of Barbagli and the dorsal inlay technique of Asopa buccal mucosal graft urethroplasty provide similar success rates. The Asopa technique is easy to carry out, provides shorter operative time and less blood loss, and it is associated with fewer complications for anterior urethral stricture repair.
... Furthermore, whilst the size of the dorsal wall defect may be proportionately the same as for primary repair, in absolute terms the size of defect that is required to re-epithelialize will be much larger in an adult penis. The problem is overcome by quilting a free © 2 0 0 4 B J U I N T E R N A T I O N A L graft of buccal mucosa (or inner preputial skin if still available) into the dorsal defect26272829 , thereby creating a graftaugmented Snodgrass or 'Snod-graft' repair (Fig. 5). Free augmentation grafts in the adult penile urethra should be placed as dorsal inlays rather than ventral onlays, because the ventral soft tissues of a hypospadiac penis provide poor vascular and mechanical support for a free graft. ...
Article
Hypospadias is repaired by paediatric surgeons, paediatric urologists, adult reconstructive urologists and plastic surgeons. This review is unique in representing all four specialities, to provide a unified policy on the management of hypospadias. The surgeon of whichever speciality should have a dedicated interest in this challenging work, ideally having an annual volume of at least 40-50 cases. The ideal time for primary repair is at 6-12 months old, although when this is not practicable there is another opportunity at 3-4 years old. A surgical protocol is presented which emphasises both functional and cosmetic refinement. Using a logical progression of a very few related procedures allows the reliable correction of almost any hypospadias deformity. A one-stage repair is used when the urethral plate does not require transection and its axial integrity can be maintained. Occasionally, when the plate is of adequate width and depth, it can be tubularized directly using the second stage of the two-stage repair. When (usually) the urethral plate is not adequately developed and requires augmentation before it can be tubularized, then that second-stage procedure is modified by adding a dorsal releasing incision +/- a graft (alias Snodgrass and 'Snodgraft' procedures). The two-stage repair offers the most reliable and refined solution for those patients who require transection of the urethral plate and a full circumferential substitution urethroplasty. From available evidence this protocol combines excellent function and cosmesis with optimum reliability. Nevertheless, it would be complacent to assume that these gratifying results will be maintained into adult life. We therefore recommend that there is still a need for active follow-up through to genital maturity.
Article
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Introduction. Infertility is diagnosed in 10–15 % of couples wishing to have children. In about half cases, the cause is a disorders of male fertility. Defects of spermatogenesis are often caused by the damages of key events of prophase I meiosis – synapsis, repair, recombination nd desynapsis of homologous chromosomes. All these events are connected with the unique structure of the meiotic nucleus – the synaptonemal complex. Behavior of the lateral elements of the synaptonemal complex serve as a paradigm of chromosome behavior in the meiosis prophase and an indicator of disorders of the chromosome synapsis. Objective is the evaluation of the possibilities analysis of the spread spermatocyte nuclei for establishing the causes and mechanisms of spermatogenesis disturbance and identification of the genetic and reproductive risks of using testicular spermatozoa for in vitro fertilization programs using intracytoplasmic sperm injection. Materials and methods. The material of the study were the biopsies of testes obtained from infertile patients by method of open multifocal testicular biopsy. The suspensions of testicular cells were examined by light microscopy. The structure of the synaptonemal complexes in spread nuclei of primary spermatocytes was studied by electron microscopy. The target meiotic proteins in such nuclei (SCP3, RAD51, MLH1, γH2AX) were localized by the fluorescence microscopy. Results. There were described possibilities of light microscopic analysis of the testicular cells suspensions for the evaluation of spermatogenesis. The features of the structural organization of the sex (XY) bivalent were presented which underlie the determination of the stages of meiotic prophase in human spermatocytes. The signs of the meiotic arrest, the disturbance of the architectonics of meiotic nuclei, synapsis, recombination and chromatin silencing in human spermatocytes at the meiotic prophase I are described in details. Сonclusion. The presented results demonstrate the expediency of introducing methods of electron microscopy and immunocytochemical analysis of the spread spermatocytes nuclei in the practice of the reproductive centers. The using of these methods makes it possible for understanding the mechanisms of infertility genesis, revealing genetic and reproductive risks of using testicular spermatozoa in the fertilization program.
Article
Objectives: To investigate the safety, efficacy and versatility of dorso-lateral graft urethroplasty using penile skin. Methods: Between 2010 and 2013, 37 men with anterior urethral strictures underwent dorso-lateral graft urethroplasty using penile skin by a single surgeon (EP). Inclusion criteria were patients with anterior urethral strictures. Exclusion criteria were Lichen Sclerosus-related strictures, absence of available penile skin because of previous surgery, obliterative urethral strictures. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation. Results: Mean (±SD) patients age was 51(±15.4) years. Stricture etiology was iatrogenic in 25 cases (67%), unknown in 10 (27%), trauma in 2 (6%). Stricture site was penile in 21 (57%) and peno-bulbar in 16 (43%). Median (range) stricture length was 5 cm (1-15). Of 37 patients, 30 patients (81%) had received previous treatments. Median (range) follow-up was 21 months (12-47). Of 37 patients, 34 (92%) were successful and 3 (8%) failures. The 3 failed patients were treated with urethrostomy and are awaiting further reconstruction. Study limitations include the small sample size and the limited follow-up. Conclusions: With a mid-term follow-up time, the dorso-lateral graft urethroplasty using penile skin showed to be a safe, efficient and versatile technique for the repair of short-mid-long anterior urethral strictures.
Chapter
Buccal mucosa has received increased attention in the field of urological reconstructive surgery because it is readily available, is easily harvested from the cheek or lip and it leaves concealed donor site scar. Surgical treatment of adult penile and bulbar urethral strictures has been a constantly evolving process and considerable changes have recently been introduced. Here we report the development and the evolution of buccal mucosal graft urethroplasty with a detailed surgical techniques. We describe penile one-stage dorsal inlay buccal mucosa graft urethroplasty, ventral onlay buccal mucosal graft urethroplasty and dorsal onlay buccal mucosal graft urethroplasty. As free grafts have been making a comeback, with fewer surgeons using genital flaps we found that short bulbar strictures are amenable using primary anastomosis, with a high success rate. Longer strictures are repaired using ventral or dorsal graft urethroplasty, with the same success rate. New tools such as fibrin glue or engineered material will become a standard in future treatment. In reconstructive urethral surgery, the superiority of one approach over another is not yet clearly defined. The surgeon must be competent in the use of various techniques to deal with any condition of the urethra presented at the time of surgery. KeywordsBuccal mucosa–Graft–Urethroplasty–Urethra–Stricture–Fibrin glue
Article
Full-text available
To explore the feasibility of applying a dorsal free graft to treat urethral stricture by the ventral sagittal urethrotomy approach without mobilizing the urethra. Twelve patients with long or multiple strictures of the anterior urethra were treated by a dorsal free full-thickness preputial or buccal mucosa graft. The urethra was not separated from the corporal bodies and was opened in the midline over the stricture. The floor of the urethra was incised, and an elliptical raw area was created over the tunica on which a free full-thickness graft of preputial or buccal mucosa was secured. The urethra was retubularized in one stage. After a follow-up of 8 to 40 months, one recurrence developed and required dilation. The ventral sagittal urethrotomy approach for dorsal free graft urethroplasty is not only feasible and successful, but is easy to perform.
Article
Purpose: We report the early outcome of dorsal full-thickness penile skin grafts in the repair of bulbar urethral stricture. Materials and Methods: During 21 months 29 men with a mean age of 43 years (range 10 to 81) underwent dorsal onlay graft urethroplasty. Followup included retrograde urethrogram at 3 weeks, 3 months and 12 to 18 months, and thereafter when needed. Urinary flow was recorded as subjectively reported by the patients. Results: The technique was used only for bulbar urethral strictures. A total of 23 patients (79%) had undergone previous direct vision urethrotomy and/or open surgery. Dorsal onlay graft urethroplasty was used alone in 12 patients (41%), and was performed with partial stricture excision and ventral strip anastomosis in 13 (45%). In another 4 patients (14%) the procedure was combined with an Orandi flap because the stricture extended significantly into the penile urethra. Penile skin grafts were used in 27 patients (93%), whereas buccal mucosa was harvested in 2. Mean graft length was 6 cm. (range 3 to 9), and width ranged between 1.5 and 3 cm. Outcome was favorable in 28 patients (97%) for a median followup of 19 months (range 10 to 37). One patient had symptomatic proximal stricture recurrence and 3 had radiographic evidence of caliber decrease of the repair but with no impact on urinary flow. Conclusions: Dorsal onlay graft urethroplasty is a versatile procedure which may be combined with stricture excision and ventral strip anastomosis or an Orandi flap. Conceptually the technique offers the advantages of spread fixation of the graft on a fixed well vascularized surface, which may improve graft neovascularization, reduce graft shrinkage and avoid sacculation. Although the early outcome is promising, dorsal onlay graft urethroplasty has yet to stand the test of time.
Article
Objective To compare the surgical outcome using buccal mucosal free grafts in the Barbagli procedure (dorsal stricturotomy and patch technique) with the traditional ventral approach, for long bulbar urethral strictures. Patients and methods Over a period of 6 years, a total of 71 patients with bulbar urethral strictures underwent buccal mucosal graft urethroplasty. Twenty-nine patients had a traditional ventral urethroplasty and 42 were managed by the Barbagli procedure with the stricturotomy and patch on the dorsal aspect of the urethra. Results At 5 years of follow-up 5% of patients who underwent the Barbagli procedure developed recurrent strictures, compared to 14% in the traditional ventral stricturotomy group. All patients developed postmicturition dribble of urine to some degree, which was troublesome in 17% in the Barbagli group and 21% in the ventral stricturotomy group. Complications attributable to out-pouching of the graft were not seen in either group. Conclusions The dorsal stricturotomy and patch (Barbagli) procedure had a higher success rate than the traditional ventral urethroplasty. Comparing these results with our experience of skin inlay urethroplasty, buccal mucosal grafts seem to have advantages however they are used.
Article
We present details of our current techniques for skin graft urethroplasty. We believe that careful attention to the details of these operative techniques is important to their success. The changes from our previous reports include: 1) preparation of patch grafts with rounded ends, 2) preparation of tube grafts with fishmouth spatulation, 3) fixation of the stent catheter to the anterior abdominal wall, 4) leaving a stent catheter inlying for 2 weeks and replacing with a smaller catheter if a voiding cystourethrogram shows extravasation, 5) fixation of the graft during preparation by dermatome adhesive, 6) irrigation of the wound with irrigant before closure and 7) urodynamic flow study for non-invasive postoperative followup.
Article
Dorsal free graft urethroplasty was performed to reduce the incidence of urethrocele. We treated 12 patients with penile and 13 with bulbous strictures. Of the 13 patients with a bulbous stricture 6 received a dorsally placed tube graft and 7 received a patch graft. Temporary fistulas were seen on postoperative urethrography in 5 cases but they all resolved spontaneously. At a mean followup of 35.8 months clinical and radiological findings were excellent in 23 cases and good in 2. No signs of graft weakening, such as post-void dribbling or diminished ejaculation, were apparent. The use of free skin grafts for urethral reconstruction is anatomically healthier in the dorsal than in the ventral position.
Article
To report the use of one-stage dorsal free-graft urethroplasty to reduce the incidence of urethrocele. From 1990 to 1994, 20 men (age range 21-86 years) underwent a one-stage dorsal free-graft urethroplasty of bulbar urethral strictures (iatrogenic in 12, traumatic in three, inflammatory in three and unknown in two). All patients except one had been treated previously by optical urethrotomy from one to 14 times. Temporary fistulae were detected on post-operative urethrography in three patients with particularly long grafts, but they all resolved spontaneously. Within a mean follow-up of 46 months, only one patient had a short recurrent stricture, which was treated successfully by optical urethrotomy. Two patients complained of post-voiding dribbling, but radiographic studies never showed graft weakening and the urinary flow rate was always > 14 mL/s. Free skin grafts can be applied successfully to the dorsal aspect and by doing so the complications of urethral reconstruction can be reduced.
Article
Preputial skin graft is used routinely for urethral reconstruction in patients with stricture disease. Alternative donor sites include extrapenile skin, bladder mucosa and buccal mucosa. Recently buccal mucosa graft has been suggested when local epithelial tissue is not available. We describe our experience with 37 patients undergoing 1-stage correction of bulbar urethral stricture using a penile skin (31) or buccal mucosa (6) graft. In 37 patients with bulbar urethral strictures a nontubularized dorsal onlay graft was used for urethral reconstruction. A preputial skin graft was used in 31 patients and a buccal mucosa graft in 6 with a paucity of local skin. Buccal mucosa graft length ranged from 2.5 to 5 cm. (average 4) and preputial skin graft was 2.5 to 12 cm. long (average 4.7). A dorsal approach to the urethral lumen was used in all patients who underwent onlay graft urethroplasty. Mean followup was 21.5 months for all 37 patients, 23 months for 31 treated with preputial skin graft and 13.5 months for 6 treated with buccal mucosa graft. The clinical outcomes were considered a failure anytime postoperative instrumentation was needed, including dilatation. In the series 34 cases (92%) were classified as a success and 3 (8%) as failure. Onlay graft urethroplasty provided excellent results in 92% of adults with bulbourethral stricture. The dorsal approach to the urethra allowed the use of foreskin or buccal mucosa graft for reconstruction of the adequate urethral lumen.
Article
A modified 1-stage penile flap onlay reconstruction is presented for patients with a long stricture in whom the urethral plate is deficient or absent. Of 37 patients who underwent transverse penile island flap onlay urethroplasty 3 men and 1 boy required simultaneous augmentation (2) or replacement (2) of an inadequate urethral plate. The 15-year-old boy had persistent severe chordee after multiple hypospadias procedures. A dorsal buccal mucosal graft was used in 3 cases and cadaveric dermal graft was used in 1. The goal of dorsal graft application in each case was to create a uniform urethral plate 1 cm. wide to promote successful 1-stage penile flap onlay reconstruction. No patient has required further instrumentation and all void without difficulty. In the 15-year-old boy chordee has completely resolved. Using dorsal grafts to salvage an inadequate urethral plate during 1-stage penile island flap onlay reconstruction obviates flap tubularization.
L'elargissement de l'urètre au moyen du plan sus urètral. Bilan après 13 ans.
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