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Asian Journal of Andrology (2020) 22, 134–139
www.asiaandro.com; www.ajandrology.com
Tubularized substitution (i.e., replacing a diseased segment of
urethra by excising it and replacing it by a tubularized ap/gra)
is sometimes necessary if there is no remnant healthy spongiosum,
as occurs infrequently in LS but is de facto in hypospadias surgery-
related strictures (absence of a urethral plate as the old skin tube-based
reconstruction has failed).12,13 However, this type of reconstruction is
associated with less satisfactory results and is usually avoided in favor
of a two-stage reconstruction.12,14
Nonetheless, in selected cases, we have been able to excise the
spongiobrosis and create a neourethral plate using BMG, as one would
do in the rst stage of the classical staged approach, and tubularize it in
the same surgical procedure. We consider this “two-in-one” approach
as distinct from other single-stage repairs using oral tissue to augment
the urethral plate such as the dorsolateral onlay15 or dorsal onlay16 or
inlay techniques.17
e aim of this study is to evaluate the suitability of selected patients
with penile urethral strictures for this two-in-one stage approach to
penile urethroplasty. Outcomes were evaluated and compared to those
INTRODUCTION
Strictures involving the penile urethra, which cannot be excised due
to resultant shortening of the urethra and penile curvature, require
augmentation or substitution using free gras or vascularized local
skin aps.1
e options for local aps include preputial, penile, or scrotal skin.
Buccal mucosa gra (BMG) has become the most commonly utilized
free gra2 due to its availability, relative ease of harvesting, low patient
morbidity,3,4 the excellent outcomes associated with its use,5–7 and its
resistance to lichen sclerosus (LS) recurrence.8
In many instances, a staged approach is necessary. e classical
staged reconstruction includes a rst operation, with removal of the
scarred tissue and placement of a gra to create an adequate-sized
neourethral plate. Aer a healing time of 3–6 months, once the gra
has achieved its neovascularization,9,10 the second stage is performed
during which the edges of the gra are mobilized and tubularized,
and closed in layers to avoid postoperative complications such as
urethrocutaneous stulation (UCF).11
INVITED ORIGINAL ARTICLE
Single-stage tubular urethral reconstruction using
oral grafts is an alternative to classical staged
approach for selected penile urethral strictures
Felix Campos-Juanatey1,2, Simon Bugeja1,3, Mariya Dragova1, Anastasia V Frost1, Stella L Ivaz1,
Daniela E Andrich1, Anthony R Mundy1
Penile urethral strictures have been managed by a staged surgical approach. In selected cases, spongiofibrosis can be excised,
a neo-urethral plate created using buccal mucosa graft (BMG) and tubularized during the same procedure, performing a “two-
in-one” stage approach. We aim to identify stricture factors which indicate suitability for this two-in-one stage approach. We
assess surgical outcome and compare with staged reconstruction. We conducted an observational descriptive study. The data
were prospectively collected from two-in-one stage and staged penile urethroplasties using BMG in a single center between 2007
and 2017. The minimum follow-up was 6 months. Outcomes were assessed clinically, radiologically, and by flow-rate analysis.
Failure was defined as recurrent stricture or any subsequent surgical or endoscopic intervention. Descriptive analysis of stricture
characteristics and statistical comparison was made between groups. Of 425 penile urethroplasties, 139 met the inclusion
criteria: 59 two-in-one stage and 80 staged. The mean stricture length was 2.8 cm (single stage) and 4.5 cm (staged). Etiology
was lichen sclerosus (LS) 52.5% (single stage) and 73.8% hypospadias related (staged). 40.7% of patients had previous failed
urethroplasties in the single-stage group and 81.2% in the staged. The most common stricture locations were navicular fossa
(39.0%) and distal penile urethra (59.3%) in the single-stage group and mid or proximal penile urethra (58.7%) in the staged
group. Success rates were 89.8% (single stage) and 81.3% (staged). A trend toward a single-stage approach for select penile
urethral strictures was noted. We conclude that a single-stage substitution penile urethroplasty using BMG as a “two-in-one”
approach is associated with excellent functional outcomes. The most suitable strictures for this approach are distal, primary,
and LS-related strictures.
Asian Journal of Andrology (2020) 22, 134–139; doi: 10.4103/aja.aja_78_19; published online: 2 August 2019
Keywords: anterior urethral stricture; hypospadias; lichen sclerosus; oral mucosa; reconstructive surgical procedures; tissue transplants
1Reconstructive Urology Unit, Institute of Urology, University College London Hospitals, London W1G 8PH, UK; 2Department of Urology, Marques de Valdecilla University
Hospital, Institute of Investigation Valdecilla (IDIVAL), Santander 39008, Spain; 3Urology Unit, Mater Dei Hospital, Msida MSD 2090, Malta.
Correspondence: Dr. AR Mundy (tony.mundy1@nhs.net)
Received: 11 March 2019; Accepted: 21 May 2019
Open Access
Operational Andrology
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in patients undergoing a classical staged reconstruction using BMG
for penile strictures during the same time period.
PATIENTS AND METHODS
Study design and population
An observational descriptive study was designed. e data from
patients who underwent penile urethroplasty in a single institution
(Institute of Urology, University College London Hospitals, London,
United Kingdom) during the 11-year period between January 2007 and
December 2017 were collected from our prospective patient outcome
database. is study was conducted in accordance with the Declaration
of Helsinki. No specic local ethics committee approval was required
for this study due to its nature. All informed consent forms used were
previously reviewed by the Ethics Committee.
Inclusion and exclusion criteria
Only patients undergoing penile urethroplasty using oral grafts
(from the cheeks and/or tongue), either in a single-stage or a staged
approach, were included in the analysis. A minimum follow-up of
6 months was required aer a single-stage procedure or aer the nal
stage of a staged approach to assess the outcomes. Patients having
posterior auricular grafts, local skin flaps, and marsupialization
procedures were excluded from the study. In the group of patients
with a single-stage reconstruction, only those with a “two-in-one”
reconstruction of the damaged segment were selected, and patients
undergoing urethral augmentation procedures were excluded.
Data collection
e information was collected prospectively with outcomes updated
during regular follow-up appointments at 3 and 12 months and
annually thereaer. e data related to stricture etiology, location,
and length, as well as previous failed treatments, were retrospectively
collected by analyzing patient charts and operation reports. Outcome
was assessed clinically, radiologically, and by ow-rate analysis.
Outcome measurement
Failure was defined as recurrent stricture on ascending/descending
urethrogram or if the patient was not satised with the surgical outcome. e
need for any subsequent surgical intervention, including urethral dilatation,
repair of UCF, or repeat urethroplasty, was also considered as failure.
Statistical analyses
A descriptive analysis of the patients undergoing the single-stage repair
for penile urethral strictures was performed. Comparison with the
classical staged approach group over the same period was made using
the Chi-squared test for categorical variables, and Wilcoxon rank-sum
test for continuous variables, as normal distribution was not conrmed.
A binary logistic regression model was used for analyzing temporal
trends. All P values were two-sided with signicance considered at
P < 0.05. Statistical analysis was performed using Stata 13.1 for Mac
(StataCorp LLC, College Station, TX, USA).
Two-in-one stage approach: surgical technique
All patients underwent preoperative evaluation including ascending
and descending urethrogram and ow-rate analysis (Figure 1). Patients
were appropriately counseled and consented for both a single-stage
repair or a staged repair and the decision as to which procedure was
performed was only made aer careful intraoperative assessment
(see below). Antibiotic prophylaxis (gentamicin and co-amoxiclav)
was administered on induction of anesthesia. Nasal intubation was
performed in all cases to allow unobstructed access to the mouth for
harvesting the oral gra.
A ventral stricturotomy was performed. e glans was incised in
the dorsal midline to deepen the glans cle and develop the glans wings
in patients with hypospadias. In patients with LS-related navicular
fossa strictures (and those associated with failed previous hypospadias
surgery), all scar tissue was excised down to the corporal heads to create
a well-vascularized gra bed (Figure 2). A circumcoronal incision and
degloving of the penis was used when the stricture extended proximally
into the penile urethra. e stricturotomy was extended proximally into
healthy mucosa. An appropriately sized buccal mucosal gra was then
harvested and prepared, trimming all the fatty and muscular tissue. e
gra was then quilted dorsally to create a neourethral plate wide enough
to allow tubularization over at least a 20/24F Clutton’s metal sound.
Aer careful assessment of the quality of the surrounding tissues,
the size of the glans, and the quality of the dartos available, the
neourethra was tubularized using interrupted sutures. ree-layered
closure was performed using the glans wings and dartos to support
the repair. When tissue mobility was inadequate to achieve a tension-
free closure or in the presence of a small glans or paucity of dartos, a
decision was made in favor of a staged approach.
A 16F silicon Foley catheter was left in situ. Two doses of
intravenous antibiotics were administered postoperatively. Patients
were discharged home the day aer surgery. e catheter was removed
two weeks later if a pericatheter urethrogram at that time showed
no leak. Clinical, ow-rate, and radiological follow-up was carried
regularly at time intervals described above.
RESULTS
Cohort selection
Four hundred and twenty-five urethroplasties for penile urethral
strictures were carried out during this time period in our institution: 149
in single-stage and 276 in staged procedures. Of these, 275 urethroplasties
involved the use of BMG. One hundred and forty-nine were single-stage
urethroplasties whereas 126 were staged. In the group having a one-
stage repair, 38 patients underwent either a dorsal inlay BMG through
a ventral urethrotomy or a dorsal or dorsolateral BMG augmentation via
a transperineal approach, leaving 83 patients who satised the inclusion
criteria for the study, having undergone a pure “two-in-one” penile
urethroplasty. Aer excluding patients who were lost to follow-up or
with incomplete follow-up time, our nal sample included 139 patients:
80 in the staged repair group and 59 in the “two-in-one.”
Strictures treated by two-in-one stage and staged approaches
Stricture characteristics and outcomes of the repair are summarized
in Tab l e 1. e etiology of strictures treated in a two-in-one stage was
LS in 31 (52.5%) and hypospadias in 23 (39.0%). e other 5 (8.5%)
strictures were related to catheterization or following transurethral
resection of the prostate (TURP). Strictures were mostly localized
Figure 1: Preoperative urethrograms of patients included in the study.
(a) Ascending urethrogram showing a short navicular fossa stricture.
(b) Descending urethrogram showing a long penile stricture.
b
a
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to the navicular fossa (n = 23; 39.0%) and distal penile urethra (n =
35; 59.3%). 40.7% (n = 24) were redo procedures aer prior failed
urethroplasty. e mean stricture length was 2.8 (range: 1.3–6) cm.
Surgical outcomes
Out of the entire cohort of 59 patients having a two-in-one stage
procedure, 53 (89.8%) had a successful outcome at a mean follow-up of
25.6 (range: 6.4–91.2) months. e average maximum ow rate (Qmax)
aer the repair was 28 ml s−1. In those having a primary procedure,
the success rate was 91.4% (32 out of 35). Redo procedures were also
associated with an excellent success rate of 87.5% (21 of 24). e success
rate was 89.0% in LS-related strictures and 87.1% following hypospadias.
Seventeen of the 23 patients with hypospadias strictures underwent a
redo procedure, which was successful in 14 (82.4%) of them.
Comparison between groups
Compared with the group of patients having a staged urethroplasty,
the distribution of etiologies is signicantly dierent (P < 0.0001),
with hypospadias-related strictures being the most common (n = 59;
73.8%). Of these, 57 (96.6%) were redo procedures. Stricture location
in this group was equally distributed throughout the anterior urethra,
with 58.7% of strictures in the proximal or mid-penile urethra and
41.3% in the distal penile urethra or navicular fossa, with a signicant
dierence in distribution (P < 0.0001) compared to the two-in-one
single-stage group. e mean stricture length was greater (4.5 cm)
compared to 2.8 cm in the group managed in a two-in-one stage
(P < 0.00001). Signicantly more strictures treated by a staged approach
had had previous attempts at repair (81.2%; P < 0.0001). e overall
success rate in this group was 81.3%, at a mean follow-up of 32 (range:
6.1–115.3) months. is success rate is not signicantly dierent to
Table 1: Stricture characteristics and outcomes of the urethroplasties using buccal mucosa graft
One‑stage repair (n=59, 42.5%) Staged repair (n=80, 57.5%) Comparison (P)
Etiology, n (%)
LS 31 (52.5) 17 (21.3) <0.0001
Hypospadias 23 (39.0) 59 (73.8)
Other*5 (8.5) 4 (5.0)
Stricture location, n (%)
Navicular fossa 23 (39.0) 4 (5.0) <0.0001
Distal penile 35 (59.3) 29 (36.2)
Mid-penile 1 (1.7) 18 (22.5)
Proximal penile 0 (0) 29 (36.2)
Procedure, n (%)
Primary 35 (59.3) 15 (18.8) <0.0001
Redo 24 (40.7) 65 (81.2)
Stricture length (cm), mean (range) 2.8 (1.3–6.0) 4.5 (2.0–12.0) <0.00001
Length of follow-up (month), mean (range) 25.6 (6.4–91.2) 32 (6.1–115.3) 0.045
Success rate, n (%) 53 (89.8) 65 (81.3) 0.163
Failures, n (%)
Restricture 3 (5.1) 8 (10.0) 0.892
Urethrocutaneous fistula 3 (5.1) 6 (7.5)
Unsatisfied with cosmesis 0 (0) 1 (1.2)
Mean improvement in Qmax (ml s−1) 28.0 26.2 0.795
*Catheter-related strictures, TURP-related strictures. BMG: buccal mucosa graft; TURP: transurethral resection of the prostate; LS: lichen sclerosus
Figure 2: Surgical technique of single-stage penile urethroplasty using
BMG. (a) Preoperative appearance in a severe LS fossa navicular stricture.
(b) Urethral exposure and location of the stricture. (c) Dorsal incision
for deepen the glans. (d) Complete resurfacing using BMG. Neo-urethral
retubularization: (e) first layer of closure; and (f) second and third layers of
closure. BMG: buccal mucosa graft; LS: lichen sclerosus.
d
c
b
f
a
e
Figure 3: Trends in penile urethroplasty using BMG. BMG: buccal mucosa graft.
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skin aps ventrally,28,29 or even with a ventral oral gra,30 in an attempt
to perform the repair in one stage in complex cases.
As a general principle, for a successful repair using a gra, the
supportive tissue must provide an adequate blood supply to guarantee
the viability of the gra. Gras placed dorsally have the advantage of
a secure scaold in the corpus spongiosum or the tunica albuginea of
the corpora cavernosa,16 and the degree of spongiosal scarring does
not inuence the take of gras when applied in this location.5
When the urethral plate is completely scarred, as in severe
LS, or inexistent, as in hypospadias, the reconstruction becomes
more complex.11 Traditionally, in patients with penile strictures,
and particularly those with extensive scarring, a tendency toward a
conventional staged approach using gras is recognized.7,14 Excising the
spongiobrosis and creating a neourethral plate with oral gras in the
rst stage, with delayed tubularization between 3 and 6 months later
once the gra has matured, is associated with success rates between
73.5% and 87% in the literature.12,14,31,32
Successful complete tubularized substitution of the urethral
segment with buccal gra in one stage was only previously reported
for strictures located in the bulbar segment.20 Even in this urethral
segment, the single-stage complete resurfacing is only for selected
strictures, as the tubularization of gras had proved to be a poor
solution in similar cases.28
In this study, we have shown that select penile strictures are suitable
for a single-stage urethral substitution with excellent results. is “two-
in-one” approach, as we describe it, is highly dependent on a careful
intraoperative assessment of the size of the glans and the thickness
of the spongiosum, which will eventually provide the vasculature
and support for the gra to allow it to be tubularized in the same
procedure. is explains why the vast majority of strictures treated by
this technique are limited to the navicular fossa and LS-related. Some
longer strictures extending into distal penile segment were also treated
successfully in this way because they retained an adequate amount
of dartos in order to support the gra and allow its tubularization.
is highlights the importance of surgeons experienced in making
the correct intraoperative decision as to whether or not a particular
stricture can be treated in this way.14
Besides navicular fossa and distal penile strictures which made
up 98.3% of the patients treated with this two-in-one stage approach,
59.3% of cases were primary repairs and 52.5% were LS-related
(compared to 39.0% associated with hypospadias). In this select group
of patients, the single-stage success rate was 89.8%.
Penile urethral reconstruction using oral gras in a single stage
oers several advantages for the patient, and this makes this novel
approach relevant. e most obvious benet would be the avoidance
of the second stage of the reconstruction associated with the traditional
staged approach.33 is advantage is even more pronounced when one
takes into consideration that almost one out of every four patients
undergoing a staged reconstruction in this series needed to have the
rst stage revised on one or more occasions before an adequate urethral
plate was created to allow satisfactory tubularization. is is in keeping
with the expected rst-stage revision between 20% and 31% published
in the literature.11,14,31 Avoidance of a proximal urethrostomy and its
negative impact on quality of life for the interim period between stages
is another obvious advantage.13,34 is temporary proximal meatus
would generate dissatisfaction on patients, as alters their body imaging
and, in severe cases, would lead the patients to void in a sitting position.
All penile urethral reconstruction techniques aimed for a repair in the
same surgical procedure, even combining dorsal graing with ventral
augmentation with aps, which is not recommended in LS patients,
that obtained with the two-in-one stage approach (89.8%, P = 0.163).
Eighteen (22.5%) patients required one or more surgical interventions
to correct gra contracture before the nal tubularization procedure.
Management of failures
Of the 6 failures in those having a single-stage procedure, 3 patients
developed recurrent strictures that have been managed endoscopically
in one and by self-dilatation in the other 2. ree patients developed
urethrocutaneous stulae, all of them successfully surgically repaired.
Reasons for failure in the 15 patients undergoing a staged repair
were comparable to those having a negative outcome with the two-
in-one stage approach (P = 0.892). Stricture recurrence occurred in 8
patients, 6 of whom have been managed with interval dilatations and
the other 2 by self-dilatation. Six patients developed urethrocutaneous
stula aer the second stage, all of which were successfully surgically
repaired. One patient was unsatised with the cosmetic appearance
aer the staged repair due to pouting of the buccal gra at the meatus,
and he underwent surgical revision.
Temporal trend analysis
During the study period, we have seen a denite overall downward
trend in the number of penile urethroplasties performed as a staged
procedure and a complimentary upward trend in those managed using
the two-in-one stage approach (P < 0.00001; Figure 3). Indeed, since
2013, more patients with select LS and hypospadias strictures were
managed using this new technique rather than a traditional staged
approach.
DISCUSSION
e treatment of urethral strictures in general is determined by
their location, etiology, length, and previous treatments or repairs.1
Strictures in the penile urethra present conceptual dierences from
bulbar strictures due to various anatomical considerations.18,19 End-
to-end anastomotic repairs are not possible due to risk of penile
shortening or penile curvature, hence the need for augmentation
or substitution techniques. e thinner spongiosum, as compared
with the bulbar segment,20 should be taken into consideration when
a graing procedure is planned in this area. In such cases, several
options have been described, using dierent substitution materials
for reconstructing the damaged segment in a single or staged
procedures.19
Ventral or dorsal urethral augmentation using local skin aps, as in
the Orandi technique using penile sha skin21 or the preputial skin ap22
are established techniques, with good outcomes in selected patients. e
use of alternative gras becomes necessary in LS patients because of the
risk of recurrence when genital or extragenital skin is used for urethral
repair.8 Buccal mucosa has become the gold standard gra tissue for
urethral replacement2 due to the ease of harvesting, its good handling
properties, a concealed donor site, and the good outcomes associated
with its use.12 Other advantages include the resistance to infection, skin
diseases, and urine exposure, as well as a rich subepithelial vascular
layer which remains stable aer transplant into the urethra.12,23 Use of
sublingual gras,24,25 in addition to the classical oral tissue harvested
from the cheek, guarantees buccal mucosa availability in almost every
patient, especially in those with long strictures or having had previous
repairs using BMG.
If the remaining urethral plate is adequate, an augmentation
procedure can be performed in a single stage, placing the oral gra in
a ventral,26 dorsal,17 or dorsolateral position,15 with or without complete
mobilization of the urethra.27 In the absence of clinical features of LS,
the dorsal placement of the gra could also be combined with local
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when the urethral plate was severely damaged. In this study, we have
demonstrated the suitability of selected patients for this single-stage
approach using oral gras for complete urethral substitution.
We have also shown that these patients have strictures with dierent
features when compared with the ones repaired in a staged manner. e
outcomes using this two-in-one stage urethroplasty technique are the
same as those achieved using the classical staged repair during the study
period. ese good results are achievable in high-volume centers, with
experienced surgeons who are able to decide the suitability of a particular
stricture for this “two-in-one” urethroplasty technique intraoperatively.
The limitations of our study arise from the nonrandomized
nature of the study and the relatively small number of cases, due
to strict inclusion criteria. e data are prospectively collected, but
retrospectively analyzed. All patients with incomplete information or
less than 6 months of follow-up are excluded. e minimum length
of follow-up is relatively short, and some recurrences may not be
detected at this stage. We set up this cut-o point considering that if
a recurrence is to occur; this usually manifest itself within 12 months
of the surgery. However, only a small number of patients have been
followed up for only 6 months. e vast majority of patients in both
groups have been followed up at least 2 years, with mean follow-up of
25.6 and 32 months. We included also some patients of each technique
having more than 5 years of follow-up since the urethroplasty. We hope
to report on long-term follow-up for this patient cohort in future. We
have designed and validated a Patient-Reported Outcome Measure
(PROMS) questionnaire for urethral surgery35,36 which we currently
use routinely in evaluating subjective outcomes. However, the study
period includes patients operated on before the questionnaire was
developed and therefore has not been included in this present study
to avoid bias.
CONCLUSION
A “two-in-one” urethroplasty using BMG for complete urethral
substitution is a suitable option for selected penile urethral strictures,
aer careful intraoperative assessment of the stricture. LS-related,
primary, navicular fossa, and distal penile strictures are usually those
more suitable for this technique. An excellent outcome, comparable
with the classical staged approach, is achievable in high-volume
centers. The advantages include improved patient satisfaction,
associated with fewer surgical interventions and avoidance of proximal
urethrostomy.
AUTHORS CONTRIBUTIONS
FCJ and SB participated in the study design, performed the literature
review, and draed the manuscript. MD performed the database
search and updated the patient outcomes. AVF and SLI contributed
to review the literature and updated the patient outcomes. DEA and
ARM performed the surgeries, also reviewed the results, discussion
and conclusion, and made critical revision and edition of the contents.
All authors read and approved the nal manuscript.
COMPETING INTERESTS
All authors declared no competing interests.
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